Metastatic tuberculous abscesses in an immunocompetent patient

The decreased incidence of infectious diseases in developed countries may make their diagnosis difficult. Cutaneous tuberculosis is an example of this fact. A 44-year-old man presented with two painful abscesses on his lower extremities, which developed into chronic ulcers. A cutaneous biopsy revealed necrotizing granulomas in the dermis. Ziehl-Neelsen and periodic acid-Schiff stain were negative. Mantoux test was positive. Tc-99m scintigraphy showed increased uptake in the bone tissue of the left ankle and right tibiae, without direct relation to cutaneous lesions. Chest X-ray showed micronodular, apical, bilateral infiltrates, reduced volume of the right lung, and cavitation of the right superior lobe. Mycobacterium tuberculosis was grown from sputum and skin biopsy samples. Isoniazid, rifampin and pyrazinamide treatment for 2 months, followed by isoniazid and rifampin for 12 months, resulted in complete resolution. The clinical features of cutaneous tuberculosis in our patient were characteristic of tuberculous abscesses. Some uncommon findings, such as the low number of lesions, negative acid-fast resistant stains in cutaneous biopsy samples and his preserved general state of health, may be explained by a higher competence of the immune system than is usual in this clinical subset of disseminated tuberculosis. Cutaneous tuberculosis should be included in the differential diagnosis of cutaneous abscesses in immunocompetent patients.     

Tuberculous gumma (cutaneous metastatic tuberculous abscess) with underlying lymphoma

Cutaneous tuberculosis is an infrequent first sign of disseminated tuberculosis. We describe a patient with 2 cutaneous ulcerations that grew Mycobacterium tuberculosis. Despite an initial response to antimycobacterial therapy, the fever relapsed. After several months, biopsy of a single cervical lymph node showed a T cell-rich B cell lymphoma. Our patient had metastatic tuberculous abscesses (tuberculous gummas), which are secondary to disseminated tuberculosis, and an underlying occult lymphoma, both believed to be sequentially presenting as a fever of unknown origin.     

Metastatic tubercular gummas and splenic tuberculoma secondary to tubercular lymphadenitis in an immunocompetent female

Tubercular gummas and splenic tuberculomas are rare forms of extrapulmonary tuberculosis, usually occurring in immunocompromised individuals. We hereby report a rare combination of multiple tubercular gummas and splenic tuberculoma secondary to TB lymphadenitis in an immunocompetent individual. The patient responded to antitubercular therapy. Thus, in a developing country like ours, tuberculosis can present in a wide clinical spectrum even in an immunocompetent individual.     

Metastatic colorectal carcinoma: an unusual presentation

Cutaneous metastases from colorectal carcinomas occur infrequently, usually in the setting of disseminated disease. They most commonly appear on the abdominal wall or perineal area; metastases to other locations of the skin are rare. We describe a case of colorectal signet ring carcinoma with metastasis to the upper lip. To the authors' knowledge, this is the second reported case of colorectal carcinoma with metastasis to the lip and first with signet ring features. Because of the rarity of cutaneous metastases, the primary physician or pathologist may overlook this diagnosis. However, this entity should be considered in the differential diagnosis of adnexal tumors as it may be the initial presentation of the colon carcinoma.     

Richner-Hanhart syndrome (tyrosinemia II): early diagnosis of an incomplete presentation with unusual findings

We report a 2-year-old girl with an incomplete form of Richner-Hanhart syndrome (tyrosinemia II) whose presenting sign was the appearance of vesicles on the fingertips. In a few months these lesions evolved into typical hyperkeratotic plaques also involving the palms and soles. Photophobia and frequent tearing were observed but there was no intelligence impairment. Serum and urine tyrosine levels confirmed the diagnosis. A low tyrosine and phenylalanine diet permitted good control of the disease with a complete resolution of the oculo-cutaneous symptoms in a month. We emphasize the importance of an early diagnosis of this syndrome to avoid the risk of mental retardation.     

Sclerosing dermatofibrosarcoma protuberans (DFSP): an unusual variant with focus on the histopathologic differential diagnosis

A 59-year-old man presented with a 10-cm x 8-cm tumoral plaque with a superficial nodule in the interscapular region of the back (Fig. 1). The lesion had been growing for 25 years. As a cystic lesion was suspected, the superficial nodule was biopsied. The histopathologic diagnosis was low-grade sarcoma with sclerosis. Two months after the initial biopsy, the lesion was completely excised, reaching the muscular fascia, with a 2-cm margin and with a free graft. Formalin-fixed paraffin-embedded samples were submitted to histologic and immunohistochemical study (4-microm paraffin sections); frozen tissue was submitted to electron microscopy. For histopathology, sections were stained with hematoxylin and eosin. Immunohistochemistry was performed following standard avidin-biotin immunoperoxidase procedures with primary antibodies for vimentin, CD34, smooth muscle-specific actin, bcl-2, S-100, desmin, myoglobin, factor VIII, p53 (all from DAKO, Copenhagen, Denmark), HHF-35 (Enzo Diagnostics, Farmingdale NY), cytokeratin (AE1/AE3) (Biogenex, San Ramon, CA), and factor XIIIa (Calbiochem Novabiochem Corporation, La Jolla, CA). At low magnification, the histologic study of the initial tumoral nodule revealed a poorly circumscribed mesenchymal proliferation, with fibroblastic-like neoplastic cells arranged in a fascicular and storiform pattern, admixed with extensive areas of sclerosis. At higher magnification, tumoral cells were spindle-shaped with hyperchromatic nuclei and scant cytoplasm. In some areas, sclerosis was so evident that a keloid-like pattern was seen (Fig. 2a). The surgical specimen showed a fibroblastic neoplastic proliferation infiltrating the dermis and hypodermis. In the dermis, cells were arranged in a storiform pattern, whereas in the hypodermis there was a honeycomb or lace-like pattern (Fig. 2b). There were also cellular areas alternating with sclerotic areas, with transitional zones in between, in both the dermis and hypodermis. The immunohistochemical study of the initial tumoral nodule and the surgical specimen showed that tumoral cells expressed vimentin, CD34 (Fig. 3), bcl-2, HHF-35, and smooth muscle actin. Neoplastic cells failed to show positivity with desmin, myoglobin, factor XIIIa, factor VIII, S-100, cytokeratin (AE1/AE3), and p53. An ultrastructural study revealed spindle cells having an irregular contour with a well-developed granular reticulum endoplasmic (REG) system in their cytoplasm, as well as some Golgi complexes and mitochondria. Also visible was the presence of many actin filaments and some myosin condensations (Fig. 4), characteristics of a fibroblastic cell with myofibroblastic differentiation. The final histopathologic diagnosis of the surgical specimen was sclerosing dermatofibrosarcoma protuberans. Two years after surgery, the patient is alive and well.     

Recurrent cutaneous herpes simplex: comments on diagnosis in an unusual case

A patient with undiagnosed recurrent cutaneous herpes of twenty-four years' duration is described. The probable reason for the failure to recognize this disease on numerous occasions was the rapid progression of the lesions to the pustular stage within one day.     

An unusual presentation of tuberculous epididymo-orchitis: case report.

An Asian man initially presented with a urethral discharge caused by lower urinary tract infection, which was followed by acute epididymo-orchitis. This responded well to antibiotics but was followed by a less acute form of epididymo-orchitis, which did not respond to antibiotics and which tissue biopsy showed to be tuberculous. The inflammatory injury of acute epididymo-orchitis may have activated a silent tuberculous focus in the epididymis, which led to the subsequent subacute tuberculous epididymo-orchitis.     

Fasciitis eosinophilica--transition to an unusual scleroderma (scleroderma-fasciitis)

Eosionophilic fasciitis (EF) was observed in a girl who suddenly developed indurations of the limbs accompanied by hypergammaglobulinaemia and peripheral eosinophilia. The deep fascia was impressively thickened and infiltrated with numerous inflammatory cells showing focal accumulations of eosinophils. The disease was progressive in spite of application of corticosteroids, and within three years, symmetrical sclerodermatous lesions developed on the face and trunk, going along with a severe sclerodactyly without Raynaud's phenomenon, as well as contractures of the upper and lower limbs causing complete disability. Visceral involvement was slight (decreased motility of the esophagus and restriction of pulmonal function); slight calcium deposits were disclosed at the soft tissue of the ankles; and nuclear antibodies of the speckled type appeared in a titer up to 320. The fascia was still the most involved tissue, but there was no peripheral or tissue eosinophilia. EF seems to be a special variant within the broad spectrum of scleroderma; and although it usually has a benign course, it may change into an unclassified variety of scleroderma and lead to severe disability.