PRIMARY CUTANEOUS NOCARDIA INFECTION DUE TO NOCARDIA ASTEROIDES

A 34-year-old white man was admitted to the hospital for treatment of cyclosporine toxicity. He was referred to the dermatology service for the evaluation of two lesions that had been present for 4 weeks on the dorsum of his left hand. The patient stated that he had cut his hand on a fence and later cleaned his aquarium two weeks before the skin lesions appeared. The past medical history was significant for a cadaveric renal transplant in 1984 for renal agenesis of the left kidney and obstructive nephropathy of the right kid-ney. His oral medications included methylprednisolone, dil-tiazem, ranitidine, cyclosporine, and ketoconazole. The recent addition of ketoconazole for oral thrush was felt to have caused the cyclosporine toxicity. The patient was cushingoid in appearance with promi-nent generalized hypertrichosis. The vital signs and the chest examination were normal. Skin examination revealed a 6-mm tense vesicle with surrounding erythema with an adjacent 5-mm firm linear papule (Fig. 1). There was no lymphadenopathy. Both lesions were biopsied, hemisec-tioned, and sent for routine light microscopy and for fungal, atypical mycobacterial, and bacterial cultures. Laboratory studies were significant for a blood urea ni-trogen of 56 mg/dL, creatinine of 2.6 mg/dL, WBC of 13,100/mm¹³, and a cyclosporine level of 2333 ng/mL (thera-peutic level 100–300 ng/mL). X-ray of the left hand showed no abnormality. Chest x-ray and computerized axial tomog-raphy scan revealed a widened superior mediastinum sec-ondary to mediastinal lipomatosis. Tissue cultures grew Nocardia asteroides. Bacterial and mycobacterial cultures, including atypical mycobacteria, were negative. The biopsy showed a mixed cellular infiltrate with scat-tered multinucleated giant cells and focal microabscesses. Brown and Brenn stain showed gram-positive filamentous organisms. A modified Fite stain (Fig. 2) demonstrated acid-fast filamentous organisms. The patient was diagnosed as having primary cutaneous nocardiosis with no evidence of dissemination. He was treated with trimethoprim sulfamethoxazole (TMP/SMX), one tablet orally four times daily, with resolution of the skin lesions within 3 weeks, but the patient developed neurolog-ic toxicity and elevation of his serum creatinine with this therapy. He was unable to tolerate a lower dose of TMP/SMX and the medication was changed to sulfisoxazole 500 mg orally four times daily, with plans to continue the treatment for 12 months. There has been no recurrence after almost 12 months of therapy.     

SPOROTRICHOID CUTANEOUS INFECTION DUE TO MYCOBACTERIUM CHELONEI IN A RENAL TRANSPLANT PATIENT.

Atypical mycobacterial infections are becoming more common in dermatological practice due to increasing numbers of immunosuppressed patients. A case of cutaneous Mycobacterium chelonei infection with sporotrichoid spread in a renal transplant patient is described, and the current literature regarding clinical spectrum, histopathology and management of infection with this pathogen is reviewed.     

CRYOGLOBULINEMIA AND CUTANEOUS LEUKOCYTOCLASTIC VASCULITIS WITH HEPATITIS C VIRUS INFECTION

Background. Mixed cryoglobulinemia (MC) is a systemic disorder, characterized by a typical clinical triad: purpura, weakness, and arthralgias, with visceral complications such as liver and renal involvement. The objective was to study the association between hepatitis C virus (HCV) infection and essential mixed cryoglobulinemia (EMC). Patients and Methods. Markers of HCV infection in 11 patients with cryoglobulinemia were examined and hepatitis C virus (HCV) was detected in eight of them. These patients were included in a clinical and histologic study. Anti-HCV antibodies were determined by a second-generation enzyme-linked immunosorbent assay (ELISA-2) in sera and cryoprecipitates. Studies on HCV-RNA were performed by a two-stage polymerase chain reaction (PCR) in the serum. A control group, consisting of 28 patients with other cutaneous disorders, was studied for HCV infection using ELISA-2 and PCR. Results. All patients had liver dysfunction, arthralgias, and purpura. Three patients had involvement of the peripheral nervous system, two had renal involvement, and one patient had Sjögren's syndrome. Cryocrits ranged from 3% to 20%. Six patients had type III cryoglobulinemia and the remaining two had type II. Markers for hepatitis B virus (HBV) were negative in all serum samples. Anti-HCV antibodies and HCV-RNA were positive in the serum of all the cases with MC. Anti-HCV antibodies were positive in all cases except for one of the cryoprecipitates tested. Four patients received recombinant interferon alfa. In two of them, serum aminotransferases became normal and cryoglobulins disappeared. Conclusions. The results strongly suggest that HCV infection is responsible for the cryoglobulinemia and vasculitis in patients with MC and that treatment with interferon alfa is presently the treatment of choice for such patients.     

DISSEMINATED PRIMARY CUTANEOUS HISTOPLASMOSIS

Two patients with primary disseminated mucocutaneous histoplasmosis are reported. As there was no focus of infection, active or healed, in the lung or other internal organs, it is assumed that a primary cutaneous site was the source for dissemination to the skin and mucous membrane. The organism could be cultured from the skin and mucous membrane only. No immune suppression was detected. Infection cleared with amphotericin B.     

PRIMARY LOCALIZED CUTANEOUS AMYLOIDOSIS

Fifty-seven patients with primary localized cutaneous amyloidosis (PLCA) were clinically and histopathologically reviewed. Two-thirds of patients had macular amyloidosis (MA). Intermediate cases having macular lesions with micropapules and/or lichens were identified. A spectrum for the disease is proposed, in which the less itchy classical macular variant occurs at one end and the very pruritic traditional lichen variant at the other. The salient histopathologic findings were similar in the macules, micropapules, and lichens, but were more prominent in the lichens. These consisted of hyperkeratosis, keratinocyte degeneration, satellite cell necrosis, and basal cell destruction. Amyloid deposition in the dermal papillae with transepidermal elimination, dermal melanophages, and superficial perivascular inflammation were also present. These changes represent an interface dermatitis of the vacuolar type. PLCA may be categorized under the group of dermatoses characterized by a lichenoid tissue reaction; inflammation may play a key role in mediating these disorders.     

PRIMARY CUTANEOUS IgA PLASMACYTOMA

Clinical, laboratory and pathologic findings from a case of IgA (λ-type) secreting extramedullary plasmacytoma of the skin are presented. The tumors were found first in the skin of the right upper extremity and then in the left maxillary sinus one year later. Materials were examined by peroxidase-anti peroxidase method (PAP method) and the immunofluorescence method.     

CLINICAL FEATURES OF MYCOBACTERIUM ULCERANS INFECTION

Mycobacterium ulcerans infection was first reported in patients from the Bairnsdale district in Victoria in 1937, although ulcers probably due to this organism have been described in Africa since the last century. Characteristically the disease occurs in patients resident in defined areas, and such areas have been identified in many countries throughout the world. In Victoria cases have occurred recently in patients living some distance from Bairnsdale, and there appears to have been some extension of the endemic area. At the same time cases have occurred in koalas, but there appears to be no direct transmission between the koala and human cases. The characteristic clinical features of the disease in humans are described and illustrated. In recent Victorian cases the incidence appears to be seasonal, cases appearing in late autumn and winter months. Skin testing with the test reagent Burulin may be of value when diagnostic histological or microbiological material is lacking.     

MYCOBACTERIUM MARINUM CUTANEOUS INFECTIONS ACQUIRED FROM OCCUPATIONS AND HOBBIES

Background. Nontuberculous mycobacterial (NTB) infections are not commonly diagnosed in Thailand. The dissertation of reported cases among 10 published reports of 44 cases within 20 years revealed only six cases of cutaneous infections in which M. marinum was not included. Methods. The proven cases of M. marinum infection were studied at the Institute of Dermatology, Bangkok from 1981 to 1990. The clinical data, histopathology, tuberculin test, chest x-ray, and treatments were recorded. Results. M. marinum skin infection accounted for 18 cases (81.8% of NTB skin infection), 10 men and 8 women. A history of preceding trauma occurred in 11 cases (61.1%), most of which were negligible wounds or minor abrasions. Twelve cases (66.7%) were in contact with organisms in their occupations and hobbies associated with fish and water exposure. Conclusions. Eighteen cases of M. marinum cutaneous infection acquired from occupations and hobbies were reported. The term “M. marinum cutaneous infection” or “M. marinum granuloma” instead of swimming pool granuloma or fish tank granuloma was proposed. According to this study, cotrimoxazole was the most appropriate drug for the treatment of M. marinum cutaneous infection.     

PRIMARY CUTANEOUS CRYPTOCOCCOSIS IN EGYPT

Neither systemic nor primary cutaneous cryptococcosis has ever been reported in Egypt. The case of a 14-year-old girl with a solitary primary cutaneous cryptococcosis lesion is presented. A surgical specimen proved the diagnosis, although the lesion resembled a rapidly growing epithelioma. Follow-up for 4 months did not reveal evidence of systemic involvement.     

PRIMARY LOCALISED CUTANEOUS AMYLOIDOSIS IN MALAYSIANS

A review of consecutive biopsies from 85 Malaysian patients with primary localised cutaneous amyloidosis (PLCA) revealed 63 with papular amyloidosis (PA) and 22 with macular amyloidosis (MA). PLCA appeared to affect the Chinese more frequently than the other major ethnic groups but MA was more common than expected among the Indians. Of patients with PA, one had systemic lupus erythematosus, one scleroderma and in another, connective tissue disease was suspected. MA was not found to be associated with any other disease. Histologically, PA differed from MA by the larger size of amyloid deposits in the papillary dermis. There was no difference in their tinctorial and immunohistochemical characteristics. Deposits were permanganate-resistant and negative for AA protein, immunoglobulin light chains and keratin. A few cases exhibited positively for cytokeratin. Strong immunoreactivity for AP protein was observed. PA and MA appear chemically similar and are likely to be of epidermal origin.     

FAMILIAL OUTBREAK OF PRIMARY HERPES INFECTION

SUMMARY.— Within a few days of each other 3 sisters between the ages of 6 and 13, who were the only children of the family, all developed acute primary herpes. The 2 younger ones were ill with severe blistering of mouth and lips. The oldest child had gross blistering of the tongue, but only mild constitutional symptoms. Their father had suffered for years from recurrent herpes of lips.