Cutaneous nocardiosis: report of two cases and review of the literature

Background Cutaneous nocardiosis is an uncommon infectious disease that presents as a primary cutaneous infection or as a disseminated disease. It is often misdiagnosed because of its rarity and nonspecific clinical picture. Methods We report a case of each type. The first case is an immunocompetent patient who was infected by Nocardia while gardening and developed a superficial skin infection – one of the three clinical manifestations of primary cutaneous nocardiosis. The second case is an immunocompromised patient with pulmonary nocardiosis that extended to the skin as part of a disseminated disease. Results The immunocompetent patient with primary cutaneous nocardiosis had the classical features of a superficial skin infection. He had a nodular–pustular lesion on the right arm, which appeared 7 days after gardening with bare hands. Nocardia was identified in a skin culture taken from a pustule, unfortunately not to the species level. Treatment with minocycline for 3 months resulted in full remission of the lesion. The immunocompromised patient with disseminated nocardiosis had high fever, productive cough, hemoptysis, and erythematous nodules and pustules on the extremities. N. brasiliensis was isolated from bronchial samples and skin. Treatment with a high dose of trimethoprim and sulfamethoxazole for five months resulted in full recovery from cutaneous and pulmonary complaints. No relapse of the infection was found on follow‐up in either patient. Conclusion These cases demonstrate the need for a high degree of suspicion, focused clinical search, and appropriate laboratory procedures in the diagnosis and management of cutaneous nocardiosis.     

Disseminated cutaneous nocardiosis mimicking cellulitis and erythema nodosum

Infection with Nocardia asteroides is a rare, life-threatening infection, which is most commonly encountered in immunocompromised patients. Cutaneous involvement is usually seen with disseminated infection but may also occur as primary cutaneous nocardiosis. We present a case of an immunocompromised patient who presented with cellulitis of the right hand and disseminated subcutaneous nodules of the lower extremities resembling erythema nodosum. Cultures from both a skin biopsy of a subcutaneous nodule on the leg as well as a surgical specimen from the debridement of her hand grew Nocardia asteroides. The patient was treated successfully with trimethoprim-sulfamethoxazole. This case likely represents primary cutaneous nocardiosis with secondary dissemination, which has been rarely reported. It also emphasizes that nocardial infection should be considered in the differential diagnosis of lesions suggestive of cellulitis or erythema nodosum in the severely immunocompromised patient.     

Chronic infection due to Fusarium oxysporum mimicking lupus vulgaris: case report and review of cutaneous involvement in fusariosis.

A 67-year-old female presented with a 20-year-old lesion involving the right ear and preauricular area mimicking tuberculous lupus. Fusarium oxysporum infection was confirmed by biopsy studies and cultures. The biopsy specimen showed an unusually extensive dermal invasion with fungal hyphae. This is an uncommon clinical presentation for Fusarium infection in a healthy patient. When referred to us, the patient had received antifungal therapy with itraconazole without any benefit. Improvement was obtained with fluconazole therapy. The spectrum of cutaneous involvement related to Fusarium spp. includes toxic reactions, colonization, superficial indolent infection, deep cutaneous or subcutaneous infections and disseminated infection.     

Cutaneous acanthamoebiasis in a lung transplant patient

BACKGROUND: Cutaneous acanthamoebiasis is a rare opportunistic infection in immunocompromised patients, particularly in HIV infected patients. We report a case of a primary cutaneous Acanthamoeba infection, in a patient with a double lung transplant not infected by the HIV. CASE REPORT: A 38 year-old white man, with a double lung transplant 3 years ago, developed a painful fibrinous ulceration of the right foot, with cellulitis. A few days later, two purplish nodules were observed, surrounded by an inflammatory reaction. Histologic examination revealed trophozoite and cyst forms. Therapy was begun with intravenous pentamidine and itraconazole along with topical ketoconazole and chlorhexidine, but was ineffective. Because of the renal toxicity of pentamidine, the patient was treated by dialysis. He died six months after diagnosis of Acanthamoeba infection. DISCUSSION: Acanthamoeba, a free-living amoeba is the causative organism of few human diseases. In immunocompromised hosts (particularly HIV infected), besides granulomatous amebic encephalitis, it can provoke some cutaneous lesions such as nodules, pustules, ulcerations... Skin biopsy is diagnostic: numerous amebic trophozoites and cysts are visualized. Recommended treatments are pentamidine, itraconazole and flucytosine. Due to the morbidity and mortality of acanthamoeba infection optimal therapy must be defined.     

Indigenous leishmaniasis in Taiwan: report of a case

Taiwan is not considered an endemic area of leishmaniasis. Imported cases are encountered infrequently, and only two cases of indigenous cutaneous leishmaniasis have been reported.(1) We found one new case in the past 20 years. The patient presented with erythematous plaques on the nasal bridge and right thumb. Skin biopsy specimens from both sites revealed numerous Leishman-Donovan bodies in macrophages. There was no history of travel outside the country, and the diagnosis of indigenous cutaneous leishmaniasis was made. Polymerase chain reactions (PCR) identified the species as Leishmania tropica. The route of infection in this patient is unclear. Because pentavalent antimony, the drug of choice for leishmaniasis, is not available in Taiwan, the patient was treated with levamisole and potassium iodide, with an excellent response.     

Tumor-like herpes simplex infection in an HIV patient

A 56-year-old male, HIV-positive, presented with a 3-day history of multiple indurated erythematous nodules with superficial and well-defined erosions on his right gluteus. Skin biopsy showed ballooning-necrotic keratinocytes and cultures were positive for herpes simplex 2. Genital herpes simplex infection recurrences may not be restricted to the anterior part of the genitalia and clinical presentation in the lumbar area or gluteus must be differentiated from varicella-zoster virus infection. Tumor-like presentation is a very rare manifestation of HSV cutaneous infection. It is important to take this morphological variant into consideration not to delay the diagnosis of a viral infection, especially in an immunosuppressed patient.     

Skin manifestations of refractory anemia with excess of blasts (RAEB)

The authors describe three cases of refractory anaemia with an excess of myeloblasts in the bone marrow (RAEM), associated with pyoderma gangrenosum (PG) and vasculitis. The first patient was an 85-year old man whose RAEM had begun in 1979. In 1985, he developed pyoderma gangrenosum in the popliteal fossa and on the right heel. Histology confirmed the diagnosis. A direct immunofluorescence test on the biopsy specimen was negative. Apart from the haematological syndrome, there were no laboratory abnormalities. The cutaneous lesions disappeared after 7 weeks of treatment with prednisolone 20 mg per day. The blood disease remained unchanged. The second patient was a 71-year old woman with RAEM since 1982. In 1984, she presented with lesions of cutaneous vasculitis located on the anterior aspect of the upper third of her left leg. There was neither arthralgia nor fever, and no history of drug toxicity or infection. Beside RAEM, polyclonal hyperglobulinaemia was present. Histological examination of the skin showed evidence of vasculitis with fibrinoid necrosis of vascular walls and perivascular lympho-histiocytic infiltrate with granulocytes and slight leucocytoclasia. Direct immunofluorescence testing of the skin demonstrated intravascular complement deposits. There were no circulating immune complexes; measurements of complement and complement fractions gave normal values; no cryoglobulin was found. The cutaneous lesions recurred on two occasions in 6 months, although no drug toxicity or infection could be elicited and the haematological syndrome was unaffected. The third patient was a 67-year old man with RAEM since 1982. In 1983, an ulcero-necrotic lesion spontaneously developed on his right leg.(ABSTRACT TRUNCATED AT 250 WORDS)     

A lupus-vulgaris like atypical mycobacteriosis caused by Mycobacterium xenopi (lupus xenopi)]

A case of lupus-vulgaris-like infection caused by Mycobacterium xenopi in a 62-year-old immunocompetent female patient is presented. A large cutaneous infiltration was seen in the right periorbital region. Histological examination revealed a granulomatous reaction of epithelioid cells and giant cells. M. xenopi was isolated from biopsy material and tuberculosis could be excluded. Isoniazid was effective in healing the lesion within a year. Such infections are well known for other mycobacteria but to our knowledge had not yet been described for M. xenopi. The characteristics of human infections with M. xenopi are summarized in a review of the literature and criteria for the diagnosis of atypical cutaneous mycobacterioses are proposed.     

Panniculitic T-cell lymphoma

Panniculitic T-cell lymphoma is a rare, aggressive variant of cutaneous T-cell lymphoma, with fewer than 100 cases described. The main problem is its diagnosis, as both the clinical and the histological features may simulate benign panniculitis. We present the case of a 34-year-old male patient, who had presented with an indurated plaque, sclerodermiform in appearance, on the front of the right thigh for 4 months, later accompanied by fever and constitutional symptoms. The initial diagnosis was cellulitis, but no clinical improvement was seen despite systemic antibiotic therapy. After two skin biopsies, the patient was diagnosed with panniculitic cutaneous T-cell lymphoma. The patient was treated with 8 cycles of CHOP chemotherapy, with resolution of the symptoms.     

Case of cutaneous botryomycosis in an 8-year-old immunocompetent boy with a review of the published work

Botryomycosis is a rare chronic suppurative granulomatous infection caused by several genera of non-filamentous bacteria. The clinical and histopathological findings are similar to those of mycetoma caused by true fungi or aerobic actinomycetes. Botryomycosis is divided into cutaneous and visceral disease, with the cutaneous form being more common. Histopathology shows granules of etiologic bacteria called “sulfur granules”. Botryomycosis occurs more commonly among immunocompromised patients, although some cases have also been reported in immunocompetent patients. We report the case of an 8-year-old immunocompetent boy who visited our hospital with a 4-mm diameter subcutaneous tumor with mild tenderness on his right heel for several months. We surgically removed the tumor with an initial diagnosis of epidermal cyst. Histopathology showed sulfur granules surrounded by an eosinophilic matrix, indicating the Splendore–Hoeppli phenomenon. The granules consisted of Gram-positive cocci, leading to a diagnosis of botryomycosis. The patient was successfully treated by excision and oral trimethoprim/sulfamethoxazole (240 mg b.i.d.) for 2 weeks as adjuvant therapy. No recurrence was noted following treatment. The subcutaneous tumor in this case was smaller than the typical in botryomycosis infections. We reviewed the infection duration and tumor size in reported cases of botryomycosis in immunocompetent patients. Small tumor size may suggest that the case is in an early stage; therefore, it is important to remove and investigate these lesions proactively.     

CUTANEOUS CRYPTOCOCCOSIS: RECURRENCE FOLLOWING ORAL FLUCONAZOLE TREATMENT

A case of recurrent cutaneous cryptococcosis in an immunocompromised patient is described. The patient presented with a non-healing cutaneous ulcer due to infection with Cryptococcus neoformans. Extensive investigation failed to reveal any evidence of associated systemic cryptococcosis. Treatment with oral fluconazole resulted in complete resolution of the ulcer but after several months a second cutaneous cryptococcal lesion appeared, strongly suggesting dissemination from an underlying systemic focus. This case illustrates the hazards associated with making a diagnosis of isolated cutaneous cryptococcosis and the necessity for prolonged follow-up of patients who present in this way.     

Immediate noninvasive diagnosis of herpesvirus by confocal scanning laser microscopy

In an immunocompromised host, cutaneous herpesvirus infections may be atypical and severe. Bedside microscopic imaging allows rapid diagnosis and prompt therapy. We report the case of an immunocompromised woman whose clinical differential diagnosis included herpesvirus infection. We used confocal scanning laser microscopy (CSLM) for immediate noninvasive bedside detection of histologic patterns diagnostic of cutaneous herpesvirus infection. We found that CLSM revealed the presence of pleomorphic ballooned keratinocytes and multinucleated giant cells in a loose aggregate of keratinocytes, inflammatory cells, and debris. Findings on CSLM were identical to those of conventional histologic examination. Prompt treatment of the immunocompromised patient produced clearing of cutaneous lesions. We conclude that CLSM may be a useful tool in the diagnosis of cutaneous herpesvirus infections.     

注射维生素K1致湿疹型皮肤反应一例

[摘要] 目的 报告肌注维生素K1致湿疹型皮肤反应1例。方法 对患者的临床资料进行分析,且对本病进行了文献回顾。结果 患者女,10岁。发现右臀部一椭圆形红斑1月。起皮疹前1周曾肌注维生素K1。皮肤科情况：右侧臀部外上方可见一6cm×5cm大小、椭圆形红色斑块,其中央有一片状、密集排列、粟粒大小的水疱,局部皮温略高,质硬,有浸润感。诊断：注射维生素K1致湿疹型皮肤反应。确诊后予盐酸非索非那定片口服和他克莫司软膏外用,治疗26天后皮疹基本消退。结论 肌注维生素K1致湿疹型皮肤反应临床罕见,有特征性,应被皮肤科医生所重视。     

Cutaneous nocardiosis of the chest wall and pleura--10-year consequences of a hand actinomycetoma

We report an unusual case of primary cutaneous nocardiosis due to Nocardia otitidiscaviarum presenting first as a mycetoma of the right hand and wrist. The patient refused treatment and was lost to follow-up until he showed up 10 years later with numerous discharging large sinuses and abscesses on the upper right quadrant of the chest wall and in the right armpit. Roentgenograms revealed pleural masses. Histology was in keeping with the diagnosis of mycetoma. Treatment with amikacin, rifampicin and co-trimaxole proved to be successful.     

Mycobacterium kansasii infection in a patient presenting with porphyria cutanea tarda

Mycobacterium kansasii, an atypical mycobacterium, is an uncommon cause of cutaneous and joint disease in immunocompetent patients. We report an unusual case of infection with this organism in a patient who initially presented with purphyria cutanea tarda (PCT), and who was noted also lo have a enisled ulcer over the middle phalanx and swelling of the proximal Interphalangeal joint of the right middle finger. The cutaneous ulcer healed with minocycline, hut the joint disease required a combination of rifampicin and ethambutol before a therapeutic response was obtained.     

An interesting case of primary cutaneous actinomycosis

Actinomycosis is an infection commonly seen in tropical countries. It is characterized by chronic and progressive suppurative inflammation, typically presenting on the neck, thorax, and abdomen. Primary cutaneous actinomycosis is a rare entity, and the diagnosis requires a high index of clinical suspicion. Anaerobic cultures may be negative despite repeated attempts. Microscopic examination reveals the diagnosis in the majority of cases, and treatment requires administration of parenteral or oral penicillin for at least 6 weeks. We report a case of cutaneous actinomycosis affecting the arm. This patient was treated with phenoxymethylpenicillin.     

Cutaneous neoplasms composed of melanoma and carcinoma: A rare but important diagnostic pitfall and review of the literature

We report two cases of combined cutaneous tumors composed of melanoma and carcinoma. The first tumor presented as a 5-mm pink-blue macule over the right zygomatic arch in an 85-year-old man. Shave biopsy and immunohistochemical studies revealed that the tumor was composed of melanoma (highlighted by SOX10 and MART-1, with high Ki-67 proliferative index) intermixed with nodular basal cell carcinoma (highlighted by pan-cytokeratin and Ber-EP4). The neoplastic melanocytes were confined to the basal cell carcinoma nodules, and a diagnosis of combined melanoma in situ and basal cell carcinoma was rendered. After therapeutic excision, the patient was disease-free at 9 months after the initial diagnosis. The second tumor presented as a 6-mm pink-brown crusted papule on the right forehead in an 89-year-old man. Shave biopsy and immunohistochemical studies revealed that the tumor was composed of malignant melanoma (MM) (highlighted by S100 and MART-1) intermixed with squamous cell carcinoma (SCC) (highlighted by cytokeratin and p63), and a diagnosis of combined MM-SCC was rendered. These two cases highlight the importance of recognizing these rare types of melanocytic-epithelial cutaneous neoplasms to arrive at an accurate diagnosis that may inform appropriate disease stage and therapy.     

An unusual presentation of secondary syphilis in a patient with human immunodeficiency virus infection. A case report and review of the literature.

BACKGROUND--Syphilis has been reported to assume unusual clinical appearances and to exhibit unusual courses in patients infected with the human immunodeficiency virus (HIV) type 1. We recently observed a distinct manifestation of syphilis in an HIV-infected patient with features not previously described. OBSERVATIONS--A 38-year-old HIV-seropositive homosexual man presented with fever, chills, malaise, and a cutaneous eruption consisting of indurated, shiny, erythematous plaques that were confluent on the face and scalp leading to alopecia and extreme tautness of the skin. Initial clinical diagnoses included lymphoreticular malignancy and infection. Although cultures yielded Staphylococcus aureus, a skin biopsy specimen was diagnostic of syphilis. CONCLUSIONS--This case demonstrates an unusual clinical manifestation of syphilis in a patient with HIV infection and emphasizes the importance of considering cutaneous secondary syphilis in the differential diagnosis of virtually any inflammatory cutaneous disorder in HIV-seropositive individuals.