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

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

A Case of Skin and Soft Tissue Infection Caused by Mycobacterium abscessus

Mycobacterium abscessus (M. abscessus) is an acid-fast bacillus that''s classified as a pathogenic "rapid growing" nontuberculous mycobacteria. It is an uncommon cause of human disease, but it can cause skin and soft tissue infection after skin injury following inoculation, minor trauma and surgery. The single most important factor for determining the course and prognosis of a M. abscessus infection is the underlying immune status of the host. We report here on a 71-year-old female who presented with multiple painful erythematous cutaneous nodules on her left forearm. She had diabetes mellitus and had taken oral steroid by herself for two years because of her osteoarthritis. Histologically, granulomas and inflammatory cell infiltration were observed and M. abscessus was identified via the mycobacterial culture. We performed curettage and drainage, followed by 6 months of oral clarithromycin and the patient''s disease completely healed.     

Primary cutaneous marginal zone lymphoma associated with juxta‐articular fibrotic nodules in a teenager

Primary cutaneous marginal zone lymphoma (PCMZL) has rarely been reported in teenagers and is occasionally associated with Borrelia burgdorferi infection. Juxta‐articular fibrotic nodules represent a unique, localized fibrosing response to spirochete infections, namely Borreliosis. Herein, we report a 15‐year‐old healthy boy who presented with a 4‐year history of progressive acquisition of asymptomatic, erythematous nodules, ≤3 cm, beginning with his right forearm (3), then right arm (1) and lastly his right inner thigh (1). Biopsy showed PCMZL in three of five samples, and inflamed, fibrotic nodules, near the elbow in two. The bottom heavy lymphomatous nodules consisted of mostly small CD20+ CD43+ lymphocytes, some with plasmacytoid features. Mature plasma cells were lambda light chain restricted by in situ hybridization. The juxta‐articular fibrotic nodules were located in the deep dermis and subcutis, had peripheral plasma cell‐rich infiltrates, and showed nodular sclerosis (morphea profunda‐like) in one, and lamellar and angiocentric sclerosis in the other reminiscent of quiescent lesions of chronic localized fibrosing leukocytoclastic vasculitis. Immunohistochemistry for B. burgdorferi revealed rare positive organisms; however, polymerase chain reaction (PCR) and serology were negative for B. burgdorferi as were serologic and/or PCR assays for Bartonella henselae, Ba. quintana, Ehrlichia chaffeensis, Treponema pallidum, Helicobacter pylori and Babesia microti. No evidence of extracutaneous disease was found by the review of systems and imaging studies. A 4‐week trial of doxycycline therapy failed, whereas intralesional (IL) corticosteroid therapy induced rapid regression of his nodules. After two local recurrences, also treated with IL corticosteroids, he is well, without cutaneous disease, 20 months later. A literature review of 19 pediatric cases PCMZL reveals a similar natural history as adult PCMZL. Despite negative serology and PCR for B. burgdorferi, the occurrence of ipsilateral juxta‐articular fibrotic nodules, positive B. burgdorferi immunohistochemistry and rapid response to IL corticosteroids implicate the presence of a replicative or non‐replicative infectious (spirochetal) antigen in the initiation and promotion of this teenager's PCMZL.     

Primary cutaneous nocardiosis caused by Nocardia brasiliensis following a wasp sting

We report a case of an 87‐year‐old woman who presented with painful erythema of her right forearm 10 days after she had been stung by a wasp on her right hand. The lesion had rapidly deteriorated during the week before presentation, and treatment with antibiotics and glucocorticoids did not improve the condition. After careful evaluation, we performed cultures from the lesion aspiration, and morphological and genetic analysis of bacteria cultures confirmed a bacterial infection with Nocardia brasiliensis. The patient recovered after 3 weeks. Primary cutaneous nocardiosis due to Nocardia spp. is relatively uncommon in clinics, but it was the distance of the lesions from the affected area of the wasp sting that has made this an even rarer case and of interest to report.     

In vivo evaluation of the protective capacity of sunscreen by monitoring urocanic acid isomer in the stratum corneum using Raman spectroscopy

Background/purpose: Urocanic acid (UCA) is a major ultraviolet (UV) ray‐absorbing component in the epidermis, and it isomerizes from the trans to the cis form upon exposure to UV radiation. Continuous measurement of UCA isomers in the skin at the same area is not available using conventional methods. This study aimed to evaluate the protective capacity of sunscreen by non‐invasively monitoring the trans‐UCA (t‐UCA) amount in the stratum corneum (SC) by confocal Raman spectroscopy. Methods: In vivo Raman spectra of the skin at the cheek or volar forearm were obtained from 27 healthy Japanese volunteers of different ages (age range, 22–53 years) throughout a whole year using confocal Raman spectroscopy. Eighteen healthy male Japanese volunteers (age range, 25–52 years) were enrolled for the evaluation of the protective capacity of sunscreen. The concentration depth profile of t‐UCA relative to keratin was calculated from the Raman spectra in the 400–2200 cm⁻¹ region. Then, the integrated amount within the depth of 0–12 μm was calculated, which represented the total amount of t‐UCA in the SC. Results: The integrated amount of t‐UCA in the cheek skin was significantly lower than that in the volar forearm skin throughout a year. The amount of it in the volar forearm skin was significantly the lowest in summer, but not in the cheek skin. The amount of t‐UCA decreased immediately after UV exposure even below 1 minimal erythema dose, remained low for 1 week, and gradually increased up to the initial level about 2 weeks after UV exposure. The decrease in the t‐UCA amount was hindered by the application of sunscreen on the skin surface. There were no statistical differences in response to UV exposure between the erythema‐positive and erythema‐negative groups. Conclusions: The monitoring of the amount of t‐UCA in the SC by confocal Raman spectroscopy is a good method to assess the efficacy of sun protective substances.     

A case report and review of lymphocutaneous nocardiosis caused by Nocardia brasiliensis reported in China

Primary cutaneous nocardiosis caused by Nocardia brasiliensis is an uncommon disease. The present authors report a Chinese woman presented with lymphocutaneous nocardiosis caused by N. brasiliensis. The lesion begin with her right hand after an unknown insect sting and evolved rapidly and formed painful erythema and two subcutaneous nodules and abscesses on her right forearm in 5 days. N. brasiliensis was isolated from pustule and identified by gene sequencing. The patient received 2 weeks of combination therapy contained infusion of amoxilin potassioum clavinet and oral TMP/SMX and followed by a single therapy of oral TMP/SMX for 1 month and got a marked improvement. The present authors reviewed a case of lymphocutaneous nocardiosis caused by N. brasiliensis reported in China.     

皮肤淋巴管型孢子丝菌病1例

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

Disseminated cutaneous Mycobacterium chelonae infection in an immunocompetent host

Mycobacterium chelonae is a rare, rapidly growing, atypical acid‐fast bacillus. Disseminated cutaneous infection has been reported in immunocompromised patients. We report an immunocompetent 86‐year‐old white woman, who presented with an 8‐month history of extensive ulcerated abscess‐like nodules. Mycobacterial culture confirmed M. chelonae infection and the patient was treated with a combination of clarithromycin and tobramycin. To our knowledge, this is the first reported case of spontaneous, disseminated cutaneous disease occurring in an immunocompetent patient.     

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     

Scedosporium apiospermum: An unreported cause of fungal sporotrichoid‐like lymphocutaneous infection in Australia and review of the literature

Scedosporium apiospermum is a fungus emerging as a rare but important cause of both localised and disseminated infections in immunocompromised patients. Most cutaneous lesions present as mycetoma, however a review of the literature revealed an increasing number of cases worldwide presenting with lymphocutaneous spread resembling sporotrichosis. An 85‐year‐old man with an extensive medical history including type II diabetes mellitus and meningioma presented with crusted haemorrhagic areas on the dorsum of his left foot and multiple crusted nodules extending proximally along his leg in a sporotrichoid‐like lymphocutaneous pattern. A mycological examination and culture of the cutaneous tissue found the fungus, Scedosporium apiospermum.     

Age‐related changes in skin mechanical properties: a quantitative evaluation of 120 female subjects

Background/purpose: The most commonly used method to determine the mechanical ability of skin is the creep test using suction chamber devices. Until now, there is no scientific consensus upon which skin deformation parameters and which body sites are particularly suitable to describe age‐related changes in human skin mechanics. The aim of this study was to find those mechanical skin parameters best representing influence of aging at five different body sites. Methods: A total of 120 healthy women aged 18–65, divided into four similar age groups, were included in this study. The biomechanical properties of the skin were measured using the Cutometer^® MPA 580 on five body sites: cheek, neck, cleavage, volar forearm and back of the hand. In order to analyze parameters referred to 1 mm skin thickness, we also used 20 MHz sonography (DUB 20). Results: A high average correlation with age was found for the parameters U_a/U_f, U_r/U_e, U_r, U_r/U_f and U_a. Only low correlation with age was found for the parameters U_v/U_e, U_f‐U_a, U_f5/U_f, U_d/U_f and U_a5. The localizations cheek, forearm and neck showed the highest correlation with age, while cleavage showed only low correlation. Conclusion: According to the results of our study, we recommend the parameter ratio of elastic recovery to distensibility (U_r/U_f) as well as the gross elasticity (U_a/U_f) for evaluation of aging effects on the mechanical properties of skin. Their high correlation with age makes them particularly applicable to represent the influence of aging onto skin mechanical properties. Most suitable localizations to evaluate skin aging are cheek, forearm and neck.     

A Case of Disseminated Nocardiosis Secondary to the Skin Nodules in an Elderly Woman

Nocardiosis refers to a locally invasive or disseminated infection associated with the Nocardia species. Most infections enter through the respiratory tract and then disseminate systemically. Rarely can a primary nocardial infection of the skin spread to contiguous structures or disseminate to other internal organs in immunocompromised hosts. We describe a 70-year-old woman who suffered from recurrent nodular skin lesions on her right hand, forearm and elbow following inoculation of a traumatic injury. Analysis of the purulent exudates obtained from the nodule revealed Nocardia species. After 20 days, a chest X-ray showed newly developed multiple nodules in both lungs. The diagnosis of systemic nocardiosis was established, and we treated this case with trimethoprim-sulfamethoxazole.     

Mycobacterium haemophilum infection with prominent facial manifestation mimicking leprosy

Mycobacterium haemophilum is a slow‐growing non‐tuberculous mycobacterium that is rarely known to cause human skin infection, particularly in immunocompromised patients. We recently experienced a 69‐year‐old Japanese woman with this infection who had been under immunosuppressive treatment for recalcitrant rheumatoid arthritis. The patient showed disseminated erythematous plaques and subcutaneous nodules on the face and extremities, and interestingly, the face manifested with a striking “facies leontina” appearance. Biopsy revealed abscess and granulomatous dermatitis with the involvement of peripheral nerve bundles and the presence of innumerable acid‐fast bacilli, thus necessitating differentiation from lepromatous leprosy. M. haemophilum was identified by molecular characterization as well as by successful culture with iron supplements. Although drug susceptibility testing indicated responsiveness to multiple antibiotics administrated simultaneously for the treatment, it took over 6 months to achieve significant improvement, and we also employed concurrent oral potassium iodide administration and repeated surgical excision. This case highlights the importance of continuous combination therapy for successful outcome in this rare infection. Furthermore, application of potassium iodide for mycobacterial infection warrants further evaluation by accumulating more cases.     

Skin infection caused by Mycobacterium avium

A patient with skin infection due to Mycobacterium avium is reported. A 9–year–old female had 10 subcutaneous nodules and two ulcers on the abdomen and legs. She had no medical history of systemic disease, skin disease or immunosuppressive therapy. Cultures of a biopsy specimen and of aspirated seropurulent fluid in nodules showed acid–fast bacteria, identified as M. avium by the DNA–DNA hybridization method. We treated her with a combination of surgery and the antibiotics, cycloserine, isoniazid and clarithromycin.     

Leg ulcer caused by Mycobacterium ulcerans ssp. shinshuense infection

Background An 81‐year‐old man presented with a skin ulcer on the left forearm caused by infection with Mycobacterium ulcerans ssp. shinshuense. The patient first noticed the subcutaneous nodule with an undermined ulcer and areola on the left forearm without any episode of trauma. Methods The rod‐shaped and acid‐fast bacteria taken from the ulcerative lesion were positive for Ziehl–Neelsen staining. The bacterial colony was cultured on Ogawa slant egg medium at 28 °C. Results A clinical diagnosis of Mycobacterium infection was made. For therapy, in addition to oral clarithromycin, topical sulfadiazine silver and hyperthermia were used. One month after starting treatment, topical treatment was changed to U‐pasta (sucrose, povidone‐iodine). Four months after the onset of the disease, bacterial colonies composed of scotochromogens were identified as Mycobacterium marinum by the DNA–DNA hybridization (DDH) method. The growth speed and characteristics of the bacterial colonies were different from those of Mycobacterium marinum. Conclusions This pathogenetic bacterium was finally identified as Mycobacterium ulcerans ssp. shinshuense by the polymerase chain reaction method and 16S rRNA gene sequencing. Nine months after the onset of the disease, the ulcer was re‐epithelialized with a residual scar.     

Supportive Immunglobulingabe beim metastasierten Melanom unter Polychemoimmuntherapie nach dem „Legha‐Protokoll”

Summary: Background and Objective: Metastatic malignant melanoma as one of the most aggressive tumors has got a new and promising therapy option with the polychemoimmunotherapy according to “Legha's protocol” (5 – 7). Facing the relatively high toxicity of this therapy, especially the high rate of infections of 49 % ( 8 ), we decided to perform a supportive treatment with intravenous IgM‐enriched immunoglobulins in order to avoid infections.
Patients/Methods: From 1998 to 2002 we treated 34 patients with metastatic malignant melanoma with the polychemoimmunotherapy according to “Legha's protocol”. Four days after each course (except the first one) patients intravenously got IgM‐enriched immunoglobulins (5 ml/kg, i. e. 250 mg /kg).
Results: Out of 34 patients three patients suffered from different infections during the polychemoimmunotherapy: One patient developed a labial herpes infection after each course, another one a subcutaneous abscess on her forearm after the third course and the third patient had a gluteal abscess after the first course, that means before getting immunoglobulins. In comparison with the infection rate of 49 % given in the literature our observed infection rate as a side effect of Legha's therapy is very low (8,8 %) when combined with supportive immunoglobulins.
Conclusions: The supportive treatment with IgM‐enriched immunoglobulins during the polychemoimmunotherapy according to “Legha's protocol” can significantly reduce the rate of opportunistic infections in these secundarily immunosuppressed patients.     

Effects of lotioned disposable handkerchiefs on skin barrier recovery after tape stripping

Background/purpose: In the present work, it was studied whether repeated use of lotioned disposable handkerchiefs on tape‐stripped forearm skin was able to improve skin barrier recovery. Methods: Skin assessments included scoring of visual erythema and dryness/scaliness; and measuring of skin redness (Chromameter^® CR300), skin hydration (Corneometer^® CM825), and transepidermal water loss (Tewameter^® TM300). Four different lotioned paper handkerchiefs – randomly assigned to one of two subject groups (n=20) – were tested vs. the non‐lotioned control handkerchief. The results were also compared with those obtained using a topically applied oil‐in‐water barrier cream (Dermalex^®). Results: The three‐day lasting protocol revealed that handkerchief wiping itself delayed skin recovery, but a significantly better performance was seen for the lotioned handkerchiefs containing fatty alcohols and mineral oils. This shows that the use of lotioned tissues helps to prevent skin damage inevitably caused by the wiping process. Conclusion: The controlled pre‐damaged forearm method with tape stripping appears to be a suitable model to study the effects of repetitive wiping on irritated skin with disposable handkerchiefs of different quality. More specifically, the model seems applicable to mimic the nasolabial skin damage observed during a common cold associated with frequent use of disposable handkerchiefs.     

Centrofacial Balamuthiasis: case report of a rare cutaneous amebic infection

Free‐living amebae are ubiquitous in our environment, but rarely cause cutaneous infection. Balamuthia mandrillaris has a predilection for infecting skin of the central face. Infection may be restricted to the skin or associated with life‐threatening central nervous system (CNS) involvement. We report a case of a 91‐year‐old woman, who presented with a non‐healing red plaque over her right cheek. Several punch biopsies exhibited non‐specific granulomatous inflammation without demonstrable fungi or mycobacteria in histochemical stains. She was treated empirically for granulomatous rosacea, but the lesion continued to progress. A larger incisional biopsy was performed in which amebae were observed in hematoxylin‐eosin stained sections. These were retrospectively apparent in the prior punch biopsy specimens. Immunohistochemistry and polymerase chain reaction studies identified the organisms as Balamuthia mandrillaris. Cutaneous infection by B. mandrillaris is a rare condition that is sometimes complicated by life‐threatening CNS involvement and which often evades timely diagnosis due to its rarity and nonspecific clinical manifestations. Moreover, these amebae are easily overlooked in histopathologic sections because of their small number and their resemblance to histiocytes. Dermatopathologists should be familiar with the histopathologic appearance of these organisms and include balamuthiasis and other amebic infections in the differential diagnosis of granulomatous dermatitis.     

Spatial variations in forearm skin tissue dielectric constant

Background: Tissue dielectric constant (TDC) values measured at 300 MHz via the open‐ended coaxial line reflection method depend on the effective measurement depth and the anatomical site being evaluated. Measurements on the forearm have shown that the TDC values decrease with increasing measurement depth but the spatial variability of the TDC values among forearm anatomical positions is unknown. Our goal was to characterize the extent of such spatial variations. Methods: In 30 healthy seated women (27.4±6.5 years), TDC was measured on the forearm midline and 1.2 cm medial and lateral to the midline at sites 4, 8 and 12 cm distal to the antecubital crease. Results: The midline and medial TDC values increased progressively from 4 to 8 to 12 cm sites (P<0.001), with the largest spatial gradient along the midline. At a depth of 2.5 mm, the TDC values increased from 26.3±2.8 to 27.4±3.4 to 28.4±3.7, with a maximum difference of 8.2±10.6%. For all sites, the TDC values were significantly (P<0.001) less for increasing depths. Conclusion: The findings reveal increased TDC values along the forearm from proximal to distal, most prominent at the midline and medial positions. Because many skin‐related dermatological and biophysical studies utilize the forearm as a test target, such differences may be important to consider because TDC values in part are reflective of local tissue water (LTW). Although the variation in the TDC values among sites was less than 10%, such differences are of importance when evaluating LTW changes using the TDC method in patients with arm lymphedema that is present in variable arm anatomical locations.     

Case of leukoderma punctata after topical PUVA treatment

An 11‐year‐old Korean girl presented with a 2‐year history of asymptomatic multiple punctiform, hypopigmented and achromic spots predominantly on the outer aspect of her right forearm. She had been treated for segmental vitiligo on her right forearm with topical PUVA six times a week for 4 years at a local clinic. The lesions were very distinct, round hypopigmented macules 1–2 mm in diameter, predominantly in nonfollicular distribution ( Fig. 1 ). Not only the site where topical psolaren had been applied but also areas on her right forearm where UVA was exposed for a long time for treatment of vitiligo developed multiple punctiform hypopigmented spots. She also had PUVA lentigenes on her right forearm. Laboratory studies including complete blood cell count, biochemistry, and endocrinologic studies were all within normal limits. There was no history of inflammatory lesions antedating the hypopigmentation. Skin biopsy was taken from punctiform hypopigmented macules. There were no specific findings in the hematoxylin‐eosin stained sections. However, marked reduction of melanin and melanocytes was noted with the Fontana‐Masson stain ( Fig. 2 ) and the S‐100 stain ( Fig. 3 ). With these clinical and histological findings the patient was diagnosed as having leukoderma punctata.

Figure 1 Open in figure viewer PowerPoint Multiple, hypopigmented, and achromic spots on the right forearm