Erythema nodosum associated with reactivation tuberculous lymphadenitis (scrofula)

A 73-year-old African American female presented to our clinic with painful lower extremity lesions of 2 weeks duration. She was in her usual state of health until 3 months prior to presentation when she reported symptoms of fatigue and weakness. She also noticed an enlarging mass on the left side of her neck. She denied fevers, chills, night sweats or cough. Her symptoms were unresponsive to a course of oral dicloxacillin. The neck mass enlarged over 8 weeks and she was referred to our institution for evaluation. CT scan of the neck showed an enlarged lymph node. Ten days prior to her presentation in dermatology, a fine needle aspirate of the enlarging lymph node revealed necrotizing granulomas. Tissue was sent for routine mycobacterial and fungal cultures. Routine blood work, chest radiograph, and a tuberculin skin test were also performed. At the time of her dermatology visit she described the development of multiple new painful, non-pruritic lesions, bilaterally on the lower extremities. She also reported a red crusted area that appeared at the site of her tuberculin test that was placed subsequent to the development of her lower extremity lesions. Her past medical history was significant for Parkinson's disease, hypothyroidism and hypertension. Her current medications included l-thyroxine, estrogen and diltiazem. Her travel history was only remarkable for a trip to Jamaica the previous spring. She was born and raised in Haiti. She reported a history of a positive tuberculin skin test 20 years ago, but received no therapy. Physical examination revealed a 2 x 3 centimeter firm, nontender left lateral neck mass (Fig. 1). Her right forearm revealed an erythematous, ulcerated, indurated plaque 1.5 cm in diameter (Fig. 2.). Her lower extremities revealed tender 0.5 to 1 cm erythematous nodules below the knees bilaterally (Fig. 3). A punch biopsy of a lower extremity nodule revealed a mild pervisacular dermal infiltrate. Within the subcutaneous tissue there was septal widening. There was also a lymphohistiocytic infiltrate with a slight admixture of neutrophils within the septa of the fat lobules. There was no evidence of necrotizing vasculitis or collagen necrosis. An acid-fast stain was not performed. The histologic findings were consistent with a diagnosis of erythema nodosum. Her laboratory evaluation including CBC, electrolytes, thyroid studies, angiotensin converting enzyme level and chest radiograph were normal. Approximately 1 week after her dermatological evaluation, the fine-needle aspirate culture grew Mycobacterium tuberculosis. A diagnosis of tuberculous lymphadenitis associated with erythema nodosum was confirmed. The patient was started on quadruple therapy of isoniazid, rifampin, ethambutol and pyrazinamide. Her lower limb skins lesions rapidly resolved over the subsequent month and her neck mass also diminished in size. She completed 6 months of antituberculous therapy with complete resolution of her lymphadenopathy.     

Pemphigoid gestationis—response to chemical oophorectomy with goserelin

A 46-year-old caucasian female presented in January 1991 with a 17-year history of severe pemphigoid gestationis. She had been on systemic steroids for 10 years since her last pregnancy in 1981 and required doses of 20-80 mg prednisolone daily to control her disease. A chemical oophorectomy was induced using a new luteinizing hormone releasing hormone (LHRH) analogue known as goserelin. A complete remission occurred within 6 months of initiating this treatment and the systemic steroids were discontinued.     

A unique variant of Darier's disease.

A 45-year-old black woman presented with a chief complaint of an increasing number of "light spots" on her face, upper trunk, and legs. She had a 4-year history of a pruritic eruption on the dorsum of her hands. The eruption was particularly pruritic in the summer months. Other family members, including her sister and her daughters, reportedly had a similar dermatologic problem. The patient had been previously evaluated and biopsied by another dermatologist. The earlier biopsy was nondiagnostic, however, and she presented for further evaluation of this problem. On physical examination, the patient had hypopigmented macules along her jawline (Fig. 1), lateral neck, and upper chest. She had similar hypopigmented macules on her thighs. She had hyperkeratosis of the palmoplantar surface of her hands and feet. The dorsum of her hands had numerous coalescing, shiny, flat-topped, hypopigmented papules (Fig. 2), and several of her fingernails had distal, V-shaped notching. A punch biopsy from a papule on the dorsum of her hand was obtained. The epidermis had corps ronds present with focal areas of acantholysis above the basal layer (Fig. 3). The dermis had sparse, superficial, perivascular infiltrates composed of lymphocytes and histiocytes. These changes were consistent with our clinical diagnosis of Darier's disease (keratosis follicularis).     

Ocular complications of severe corneal abrasions after cosmetic blepharopigmentation

A 53-year-old woman with hemiparesis and poor dexterity, underwent cosmetic blepharopigmentation on the both upper eyelids in the dermatology clinic of a private hospital. She was not asked for any information on her medical history and no informed consent was obtained and the procedure was performed without any protective ocular shields. The patient experienced severe lacrimation, discomfort, and increased sensitivity to light during and after the procedure. She also noticed blurred vision after the procedure. Ophthalmologic examination revealed tender and oedematous eyelids and corneal abrasions in both of her eyes. Topical antibiotics and preservative-free lubricants were able to recover her from her signs and symptoms at 1-week follow-up. It is recommended that cosmetic blepharopigmentation should be applied cautiously with patient’s informed consent after obtaining a thorough medical history and with protective ocular shields to avoid potential complications.     

Familial yellow nail syndrome

A 70-year-old woman with yellow nail syndrome and right-sided pleural effusion, lower extremity edema, and hypoalbuminemia was followed for 18 months. She reported an 8-year history of asthma. She had four children (3 boys and 1 girl). Dystrophy, changes in color and shape of nails both hands and foot, along with lower extremity edema was observed in the daughter and two of her sons. One son had asthma. The patient reported that her grandmother had similar nail abnormality and lower extremity edema. Other family members and patient's grandchildren were healthy. This report demonstrates a case of familial yellow-nail syndrome.     

Chronic Graft-Versus-Host Disease Mimicking Psoriasis in a Patient with Hemophagocytic Lymphohistiocytosis

Graft-versus-host disease (GVHD) is a common complication of bone marrow transplantation (BMT) that can be classified as acute or chronic. Chronic GVHD, which usually occurs more than 3 months after BMT, includes typical lichenoid or sclerodermatous lesions. Psoriasiform eruption is a rare clinical manifestation of chronic GVHD, and there have been no reports of psoriasiform chronic GVHD associated with hemophagocytic lymphohistiocytosis. A 33-year-old woman who was diagnosed with hemophagocytic lymphohistiocytosis 10 years ago visited our outpatient clinic with psoriasiform eruption over her entire body. She underwent allogeneic BMT 7 months previously from her sibling. Skin biopsy was performed on the lesion, and the histological features suggested GVHD. The psoriasiform lesions improved with narrow-band ultraviolet B phototherapy, with secondary vitiligo remaining on the corresponding locations.     

Imiquimod: potential risk of an immunostimulant

A 19-year-old woman with severe HLA B27 spondyloarthropathy whose disease was controlled on cyclosporin, methotrexate and prednisolone had human papillomavirus infection and developed cervical dysplasia and a large number of cutaneous and vulval warts. These were not responsive to cryotherapy, salicylic acid or cimetidine, so she was treated with topical imiquimod 5% cream. Two weeks after starting this treatment she had a significant flare of her spondyloarthropathy. She was so ill that she stopped using the imiquimod cream. She had full resolution of her warts after 3 weeks' treatment with imiquimod cream, but her spondyloarthropathy took more than 3 months to improve, despite significant augmentation of her immunosuppression. This case highlights the potential risk of using imiquimod cream (an immunostimulant) in a patient who has a condition requiring immunosuppression, such as autoimmune disease or an organ transplant.     

Progesterone-induced urticaria: response to buserelin

Summary We report a 41-year-old Caucasian woman with polycystic liver and kidney disease, and a 9-year history of severe cyclical urticaria related to her menses. The urticaria was not adequately controlled by antihistamines or Prempak-C® (conjugated oestrogens and norgestrel). Intradermal testing with progesterone was strongly positive at 30 min and 18 h. Buserelin, administered intranasally at doses of up to 800 μg daily, controlled the urticaria within 4 weeks, and she was completely symptom-free thereafter. She had therapy-induced amenorrhoea and occasional hot flushes. Unfortunately, her liver cysts progressively enlarged, and a right hepatectomy was performed in June 1992, but she died after complications 3 weeks later. Prior to this she had been free of urticaria for 6 months after starting buserelin. Buserelin, a gonadotrophin-releasing hormone analogue, may he useful in the management of progesterone-induced urticaria, in patients in whom conjugated oestrogens are contraindicated or unhelpful.     

Generalized morphea-like progressive systemic sclerosis with anticentromere antibodies and eosinophilic cellulitis

A 67-year-old woman without any history of exposure to organic solvents suffered from Raynaud's phenomenon, sclerodactylia, contracture of finger joints, diffuse pigmentation, pulmonary fibrosis, and generalized morphea-like eruptions on the trunk; she was diagnosed as generalized morphea-like progressive systemic sclerosis. She had a high titer of anticentromere antibody in her serum without any symptoms of CREST syndrome. She also had eosinophilic cellulitis on her extremities, which subsided within 6 months, and seemed to be due to a hypersensitivity reaction to mosquito bites. The occurrence of these two diseases together in our case may suggest some similarities in their pathogenesis.     

Undiagnosed purpura: a case of autoerythrocyte sensitization syndrome associated with dermatitis artefacta and pseudo-ainhum

A 23-year-old young woman presented with recurrent episodes of painful bruising along with linear erosions on the accessible areas of the body of nine years duration with a pseudo-ainhum of her left nipple for the past three months. Her case history included repeated visits to various physicians at different centers and an extensive investigative profile. A diagnosis of autoerythrocyte sensitization was made on the basis of the clinical history, dermatological examination complemented by a positive autoerythrocyte sensitization test, psychiatric evaluation and absence of any organic cause for her ailment. She was placed on psychiatric management and has remained symptom-free after six months follow-up. The case is reported for its rarity, as well as for the association of autoerythrocyte sensitization syndrome with frank dermatitis artefacta and pseudo-ainhum, which to the best of our knowledge has not yet been reported in the literature.     

Leg ulcers and hydroxyurea: report of three cases with essential thrombocythemia

CASE 1: A 65-year-old woman with essential thrombocythemia (ET) had been taking oral hydroxyurea (HU), 1,000 mg daily, for 7 years. Six months ago, she developed an ulcer on the outer part of her left ankle, which healed spontaneously within 2 months. She presented with a new, tender, shallow ulcer, 2 cm x 2 cm in size, at the same site. Doppler examination revealed thrombosis of the left common femoral vein and a calcified atheroma plaque of the left common femoral artery. The dosage of HU was decreased to 500 mg daily when the platelet counts were found to be within normal levels. The ulcer completely healed within 2 months with occlusive wound dressings, and has not recurred within the follow-up period of 1 year. CASE 2: A 56-year-old women presented with multiple, painful, leg ulcers of 1 year duration. She had been diagnosed as having ET and had been on HU therapy, 1,500 mg/day, for the past 5 years. Interferon-alpha-2b was started 3 months ago, in addition to HU, which was tapered to 1,000 mg daily. She had suffered from hypertension for 20 years treated with nifedipine and enalapril, and had recently been diagnosed with diabetes mellitus which was controlled by diet. Examination revealed three ulcers located on the lateral aspects of both ankles and right distal toe. Arterial and venous Doppler examinations were within normal limits. Histopathology of the ulcer revealed nonspecific changes with a mixed inflammatory cell infiltrate around dermal vessels. The ulcers completely healed within 10 weeks with topical hydrocolloid dressings. After healing, she was lost to follow-up. A year later, it was learned that she had developed a new ulcer at her right heel, 3 months after her last visit (by phone call). This ulcer persisted for 8 months until HU was withdrawn. CASE 3: A 64-year-old woman with ET presented with a painful leg ulcer of 6 months' duration. She had been taking oral HU for 5 years. She had a 20-year history of hypertension treated with lisinopril. Examination revealed a punched-out ulcer of 2 cm x 2 cm over the right lateral malleolus. Doppler examination of the veins revealed insufficiency of the right greater saphenous and femoral veins. Angiography showed multiple stenoses of the right popliteal and femoral arteries. As her platelet count remained high, HU was continued. During the follow-up period of 13 months, the ulcer showed only partial improvement with local wound care.     

Contact dermatitis to Shiitake mushroom

A 44-year-old woman with occupational allergic contact dermatitis to Shiitake mushroom (Lentinus edodes), sawdust and thiuram. She presented with an 8-month history of hand and face dermatitis that developed after working for 2.5 years in a mushroom farm. Within 3 months of ceasing work at the farm, her symptoms resolved completely.     

Pericostal tuberculosis diagnosed by fine needle aspiration biopsy: report of a case with a review of the literature

We present an 81-year-old woman with pericostal tuberculosis, a rare disease recently, without a past history of pulmonary tuberculosis or tuberculous pleurisy. She developed a subcutaneous nodule on her right chest. She was suspected of skin tuberculosis after the confirmation of acid-fast bacilli in a fine needle aspiration material of the nodule. A tuberculin skin test was strongly positive. The nodule was resected, and preclusive antituberculosis chemotherapy with rifampicin and isoniazid was started. The histological findings included granulomatous changes, central necrosis and Langhans' giant cells. Mycobacterium tuberculosis was identified from a culture of the specimen. About six months after the operation, no erythema, nodule or abscess was observed. We first suspected that she had mammary carcinoma and therefore observed the nodules on the thorax; it is important to differentiate tuberculosis from neoplasms. We also reviewed 22 cases of pericostal tuberculosis in Japan reported in the 15 years from 1976 to 2002.     

Isolated cutaneous Mycobacterium avium complex infection in AIDS

A 38-year-old woman, known to be HIV-antibody-positive for 2 months, presented with a progressive swelling of the right thigh of 1-month duration. She had no history of trauma or breaking of the skin. She suffered from oral candidiasis, but had no previous AIDSdefining illness. She had no systemic symptoms such as pulmonary symptoms, weight loss, organ enlargement, or fever. Her laboratory tests were unremarkable, except for a CD4 count of 115/mm3. On examinafion, an ulcerated, fluctuating 3-cm mass with surrounding erythema was noted with only a small volume of purrulent discharge. A punch biopsy, showing a necrotizing inflammation of the hypodermis without granulomas, and a swab and two blood cultures (Isolator 10, DuPont, Wilmington, DE, USA) were performed. The patient was discharged with a diagnosis of a bacterial abscess and treated with pristinamycin, 1 g t.i.d., and local wound care. One month later, the ulceration persisted, but the inflammation and purulent discharge had disappeared. Because direct examination of a Ziehl-Neelsen stained specimen had revealed acid-fast bacilli, later identified as Mycobacterium avium complex, the therapy was changed to clarithromycin, 2 g b.l.d., given for 3 months, complete healing was obtained without incision and drainage. She was given rifabutine, 300 mg once daiiy, 7 months later as her CD4 cell count became <100/mm", No relapse had occurred after a 18-month follow-up.     

Psoriasiform drug eruption associated with metformin hydrochloride: a case report

An 18 year-old-woman presented with a 1-week history of a psoriasiform eruption on her limbs and trunk that began 1 week after starting metformin hydrochloride. She had taken no other medications. She had no personal or family history of psoriasis. The lesions disappeared within 5 weeks after discontinuation of the drug. In the 4 months following the cessation of metformin hydrochloride, no relapse was observed, but rechallenge with oral metformin again produced the eruption. Metformin hydrochloride should be added to the list of drugs that can cause a psoriasiform eruption.     

海分枝杆菌感染一例

患者，女，73岁。右上肢皮疹3个月，出疹前半个月有海鱼刺伤史。皮肤科检查：右上肢可见数枚半球形红色丘疹和结节，直径0.3~1.5 cm，沿淋巴管分布。皮损组织病理检查：表皮棘细胞增生，真皮内可见以中性粒细胞为主的混合炎症细胞浸润，偶见多核巨细胞。结核感染T细胞斑点试验(T-SPOT.TB)阳性，病原宏基因组学检测示海分枝杆菌阳性。诊断为海分枝杆菌感染。给予克拉霉素及利福喷丁治疗1个月后好转。     

Cheilitis caused by contact urticaria to mint flavoured toothpaste

A 26-year-old woman presented with a 12-month history of persistent dermatitis of the lips. She had failed to respond to cosmetic avoidance and therapeutic measures. Patch testing was negative, including her toothpaste and toothpaste flavours. She defied diagnosis until an acute flare followed immediately after dental treatment with a mint flavoured tooth cleaning powder. This led us to prick test her to mint leaves and this was positive. Her cheilitis settled after changing from her mint-flavoured toothpaste. A diagnosis of contact urticaria should be considered in cases of cheilitis of unknown cause.     

Unilateral lokalisiertes bullöses Pemphigoid nach Radiotherapie

A 74-year-old woman presented with a four-week history of locally expanding, highly pruritic urticarial plaques, bullae and erosions on her left breast. She had undergone surgery for an infiltrating ductal carcinoma of the same breast six months before and received intra- and postoperative radiotherapy (RT) followed by adjuvant hormonal anticancer treatment. Histopathological, immunological and serological data confirmed the diagnosis of localized bullous pemphigoid (BP) and treatment with systemic and local corticosteroids led to a sustained remission. After excluding other factors, we concluded that RT was the most likely trigger of her localized BP.     

Pregnancy and porphyria cutanea tarda

A 31-year-old woman developed typical clinical and laboratory signs of PCT at the end of her second pregnancy coincident with the summer season. She had elevated liver function values without history of alcoholism, hepatitis or chemical liver damage. She had taken oral contraceptive only before her first pregnancy which was normal. Her hormone analytic values including estrogens corresponded to normal values in pregnancy. Venesections had a beneficial affect on her condition.     

Gallbladder vasculitis associated with cutaneous leucocytoclastic vasculitis

A 72-year-old woman presented with a 1-week history of a painful, purpuric, pruritic rash on her legs, buttocks and arms. Skin biopsy revealed histological features typical of leucocytoclastic vasculitis. She was admitted, her usual medications were withheld, and she was commenced on ibuprofen and loratadine. The patient had undergone a laparoscopic cholecystectomy 2 months prior to her rash appearing. She had been having upper abdominal pain for 2 years and, following a more severe acute episode, an abdominal ultrasound scan had revealed a solitary cholelithiasis. Histology of the gallbladder revealed acute fibrinoid vasculitis in two small arteries, on a background of chronic cholecystitis. A mild postoperative wound infection was treated with a short course of cephalexin and no other investigations were conducted. As an inpatient, the patient's rash improved, but she progressed to develop systemic vasculitis and acute renal failure. Renal biopsy showed focal necrotizing glomerulonephritis, consistent with vasculitis. She was subsequently commenced on cyclophosphamide 100 mg daily, prednisolone 50 mg daily and one prophylactic trimethoprim/sulphamethoxazole (160 mg/800 mg) tablet 3 days/week. Following discharge, the patient's cutaneous vasculitis eventually resolved and renal function gradually improved. Her prednisolone was gradually reduced to 7 mg daily and cyclophosphamide was weaned, then substituted with azathioprine 100 mg daily.