Cutaneous findings encountered in brucellosis and review of the literature

BACKGROUND: Human brucellosis is an infectious disease produced by Brucella species: small, coccoid or rod-like, aerobic, Gram-negative bacteria. The infection is common in developing countries, and can also affect the skin. Its prevalence is high in our region of Turkey, where stockbreeding is one of the main economic sources, compared with the industrially developed areas of Turkey, and dermatologic complaints due to brucellosis are fairly common. MATERIALS AND METHODS: One hundred and three patients with serologically and clinically confirmed brucellosis were studied in order to investigate the prevalence of cutaneous findings and their variability in brucellosis. Fifty-two (50.49%) were males and 51 (49.51%) were females with an age range of 4-70 years (mean, 30.45 +/- 15.08 years). RESULTS: Of these patients, 14 (13.59%) had cutaneous findings probably related to brucellosis. These findings were more frequent in females (11 cases) than males, and most of the females (eight cases) were housewives; three were students. Urticaria-like papules and plaques were the most common findings; they were seen in six (35.3%) patients. One case had livedo reticularis and another palmar erythema, which have not been reported previously. No relationship was observed between the serologic values and the cutaneous findings. CONCLUSIONS: Cutaneous findings in our cases were more prevalent than in other reported studies. It is important to emphasize that cutaneous lesions are not specific to brucellosis and may be seen in a variety of other dermatologic diseases caused by many agents; therefore, these agents should be kept in mind in the differential diagnosis.     

Cutaneous manifestations in brucellosis

Brucellosis is a common worldwide zoonotic disease. Cutaneous manifestations are not specific and affect 1-14% of patients with brucellosis. Here, we describe 49-year-old female with fever and a diffuse maculopapular rash due to Brucella melitensis infection. Histopathology of skin biopsy revealed leukocytoclastic vasculitis; positive blood cultures for B. melitensis established the diagnosis of brucellosis. We provide a review of the relevant literature.     

Cutaneous presentation of nasal/nasal type T/NK cell lymphoma: clinicopathological findings of four cases

Epstein–Barr virus (EBV)-associated T/natural killer (NK) cell lymphoma mainly shows nasal lesions, and has recently been shown to be associated with cutaneous T-cell lymphoma (CTCL). The detailed features of CTCL nasal metastasis have yet to be elucidated. We report clinicopathological findings for four cases of cutaneous T/NK cell lymphoma with metastasis to the nose. The four patients presented progressive involvement of nasal lesions of CTCL, an aggressive course and poor outcome. Their pathological and immunohistological findings were consistent with peripheral T/NK cell neoplasm and, in three of four cases, EBER-1 were apparently detected in lymphoma cells by in situ hybridization, and two of four cases were also positive for TIA-1. The polymerase chain reaction (PCR) results showed the identical band from the skin and nasal lesions of the two patients. We also reviewed the cases of similar clinical course and attempted to elucidate clinical, pathological, immunological and genotypic features. The 10 reported cutaneous T/NK cell lymphomas with nasal metastasis revealed a poor prognosis (nine of 10 died at 3–108 months). Six cases of nine showed a positive reaction to EBV, and six cases revealed T-cell receptor β or -γ rearrangement. These findings suggest that most cutaneous T/NK cell lymphoma with nasal metastasis are similar to nasal T-cell lymphoma associated with EBV infection. This type of cutaneous T/NK cell lymphoma likely to involve nasal lesions and skin cases seemed to have a poor prognosis.     

Clinical and pathological features of posttransplantation lymphoproliferative disorders presenting with skin involvement in 4 patients

BACKGROUND: Posttransplantation lymphoproliferative disorders (PTLDs) are lymphoid proliferations that can develop in recipients of solid organ or allogeneic bone marrow transplants. They are clinically and pathologically heterogeneous and range from polyclonal hyperplastic lesions to malignant lymphomas. Although extranodal involvement in PTLD is common, cutaneous presentation is rare, with only 19 cases reported previously. OBSERVATIONS: We describe 4 patients with cutaneous presentations of PTLD. All patients had relatively late-onset PTLD (>1 year after transplantation) with a median of 8 years from organ allograft to tumor diagnosis. The extent, number, and anatomic location of skin lesions varied from a localized patch to widespread nodules. None of the patients exhibited systemic symptoms at the time of PTLD diagnosis. Pathological findings ranged from plasmacytic hyperplasia to monomorphic PTLD. In situ hybridization detected Epstein-Barr virus messenger RNA in all 3 cases with evaluable tissue. All patients underwent reduction in immunosuppressive therapy and received other individualized treatments. Median follow-up was 2.5 years. At the most recent follow-up, 3 patients were in complete remission and 1 had residual disease. CONCLUSIONS: In this study, PTLD lesions presenting in the skin responded to therapy. Despite their relatively late occurrence after transplantation, most of these cases were positive for Epstein-Barr virus. As observed with other cutaneous lymphomas, the PTLDs with predominant skin involvement had a relatively favorable outcome.     

Kaposi's varicelliform eruption. Absence of ocular involvement

The eponym Kaposi's varicelliform eruption (KVE) describes a characteristic syndrome of disseminated vesicopustules that occasionally complicates a number of dermatoses. Among these, the most common is atopic dermatitis, and the inciting agent is most often herpes simplex virus (HSV). Very few reports of ocular herpetic disease exist among the many cases of KVE reported in the literature, despite extensive cutaneous involvement with herpetic lesions. We describe 10 patients with KVE, none of whom have developed evidence of herpetic ocular disease despite widespread facial involvement in all patients. All random conjunctival swab cultures performed in 3 patients were positive for growth of viable HSV. Although ocular exposure to HSV may commonly occur in KVE, ocular pathology due to this virus does not appear to be a common sequela.     

Immune deposits in cutaneous lesions of Wegener's granulomatosis: predictor of an active disease

A retrospective analysis was conducted of eight cases of Wegener's granulomatosis (WG), who presented with cutaneous lesions. The clinical, immunopathologic and histopathologic features of the cutaneous lesions were reviewed. Antineutrophil cytoplasmic antibody (ANCA) status of the patients was established. When possible, a comparison of immunofluorescence findings of skin biopsies was made with those of renal biopsies taken at the same time. In all except one, systemic and cutaneous disease developed concurrently. On histopathology, leukocytoclastic vasculitis was noted in five patients and features of lupus erythematosus and pyoderma gangrenosum in one case each. Four patients showed immunoglobulin deposits in subepidermal blood vessel walls, while one patient showed granular immune deposits at dermo-epidermal junction only. Immunoglobulin G was the most common immunoreactant detected. C-ANCA/proteinase 3 (PR3)-ANCA was positive in six patients, P-ANCA/myeloperoxidase (MPO)-ANCA in one patient, while one patient did not show ANCA positivity on indirect immunofluorescence. All four renal biopsies showed pauci-immune glomerulonephritis, irrespective of the presence (n=3) or absence (n=1) of immune deposits in the skin biopsy. Skin manifestations are encountered in nearly half of the patients with WG, thus it is important to be familiar with cutaneous histopathologic as well as immunofluorescence findings in WG patients.     

Panniculitis as the initial manifestation of brucellosis: a case report

Here, we describe a 38-year-old male with an abrupt manifestation acute panniculitis as unusual presentation of brucellosis. Brucellosis is a reemerging disease in Turkey, and the disease is primarily transmitted from farm animals to humans. Farmers and shepherds are the major risk groups for brucellosis in Anatolia. Brucellosis may involve almost all systems and organs, including the skin, and may mimic a wide range of illness and syndromes. Although the cutaneous manifestation of brucellosis is not disease specific, but it occurs in about 6%-13% of patients with brucellosis. Some of these lesions including rashes, papules, ulcers, abscess, erythema nodosum, ecchymosed skin rash, purpura, and vasculitis may be seen frequently in brucellosis, but panniculitis is rarely described. The case confirmed by positive blood culture had manifest skin lesion as an initial finding represented by lobular panniculitis with vasculitis.     

Cutaneous tuberculosis: diagnosis and treatment

As we move into the 21st century, cutaneous tuberculosis has re-emerged in areas with a high incidence of HIV infection and multi-drug resistant pulmonary tuberculosis. Mycobacterium tuberculosis, Mycobacterium bovis, and the BCG vaccine cause tuberculosis involving the skin. True cutaneous tuberculosis lesions can be acquired either exogenously or endogenously, show a wide spectrum of morphology and M. tuberculosis can be diagnosed by acid-fast bacilli (AFB) stains, culture or polymerase chain reaction (PCR). These lesions include tuberculous chancre, tuberculosis verrucosa cutis, lupus vulgaris, scrofuloderma, orificial tuberculosis, miliary tuberculosis, metastatic tuberculosis abscess and most cases of papulonecrotic tuberculid. The tuberculids, like cutaneous tuberculosis, show a wide spectrum of morphology but M. tuberculosis is not identified by AFB stains, culture or PCR. These lesions include lichen scrofulosorum, nodular tuberculid, most cases of nodular granulomatous phlebitis, most cases of erythema induratum of Bazin and some cases of papulonecrotic tuberculid. Diagnosis of cutaneous tuberculosis is challenging and requires the correlation of clinical findings with diagnostic testing; in addition to traditional AFB smears and cultures, there has been increased utilization of PCR because of its rapidity, sensitivity and specificity. Since most cases of cutaneous tuberculosis are a manifestation of systemic involvement, and the bacillary load in cutaneous tuberculosis is usually less than in pulmonary tuberculosis, treatment regimens are similar to that of tuberculosis in general. In the immunocompromised, such as an HIV infected patient with disseminated miliary tuberculosis, rapid diagnosis and prompt initiation of treatment are paramount. Unfortunately, despite even the most aggressive efforts, the prognosis in these individuals is poor when multi-drug resistant mycobacterium are present. An increased awareness of the re-emergence of cutaneous tuberculosis will allow for the proper diagnosis and management of this increasingly common skin disorder.     

Keloid morphea and nodular scleroderma: two distinct clinical variants of scleroderma?

BACKGROUND: For nearly a century, the terms "keloid morphea" and "nodular scleroderma" have been used interchangeably without defined clinical or histologic criteria. OBJECTIVE: To define the conditions "keloid morphea" and "nodular scleroderma" by correlating the clinical and histologic features. METHODS: We retrospectively identified six patients with keloidal lesions and nodules from 70 consecutive patients with scleroderma seen in the dermatology clinic. The clinical presentation and histopathological findings were reviewed. RESULTS: Six of 70 patients with scleroderma (45 systemic and 25 morphea) exhibited keloidal or nodular lesions. All these patients had systemic sclerosis. Clinically one patient (case 1) had nodules; five (cases 2-6) had keloids. The nodular lesions had histologic findings consistent with keloid, while the keloidal plaques were variably keloids or morphea histopathologically. There was no correlation between the clinical morphology and the histologic findings, except for cases 5 and 6. These patients were African-American, with a family history of keloids and typical keloids clinically and histologically that developed from sites with normal skin. CONCLUSION: Keloid morphea and nodular scleroderma are clinical terms that describe keloidal and nodular lesions in patients most commonly with scleroderma. The clinicopathologic association is variable. Based on a review of the English literature and our series of six patients, we identified two clinical variants; (1) keloidal or nodular lesions arising from sclerodermatous skin with histologic findings of keloid or scleroderma, (2) typical keloids clinically and histologically, arising in normal skin in patients with a family history of keloids. Awareness of these entities is important for proper diagnosis of the cutaneous lesions and for recognizing that the cutaneous findings may be a sign of systemic sclerosis     

Acute bacterial septic vasculopathy

Objectives The frequency and clinicopathologic characteristics of cutaneous lesions in sepsis are not well known. This study aimed to analyze cutaneous lesions in bacterial septic vasculopathy. Methods The study population comprised 32 patients with bacterial sepsis, cutaneous lesions, and skin biopsy‐proven septic vasculopathy. The clinical and histologic characteristics of the lesions were analyzed. Findings in non‐immunosuppressed patients (NISPs) and immunosuppressed patients (ISPs) were compared. Results Nine of 32 patients were immunosuppressed. The foci of sepsis were variable; in 17 patients, the focus was not identified. Although Neisseria meningitidis was the most common causal agent, several microorganisms were identified. Cutaneous manifestations were an early event in 90.6% of patients. The most common skin signs were purpuric lesions and petechiae. Overall mortality was 28.1%; 65.5% of patients survived without sequelae. Skin biopsies showed thrombi in 100% of cases. Other common findings were inflammatory infiltrate, blood extravasation, and epidermal involvement. Bacteria within the vascular wall were seen in 21.9% of cases and fibrinoid necrosis in 25%. A comparison of ISPs with NISPs disclosed that meningococcemia was more common in the latter group, and the presence of pustules was more common in the former. Histopathology testing revealed that fibrinoid necrosis and bacterial invasion of the vessel wall were more common in ISPs than in NISPs. Conclusions Several microorganisms can cause septic vasculopathy. Clinical presentation is variable and does not depend on the microorganism or the pathogenic mechanism. Histopathologically, septic vasculopathy is a thrombo‐occlusive vasculopathy with variable morphology. Cutaneous lesions are an early event and allow for rapid diagnosis.     

Cutaneous manifestations in patients positive for anti-hepatitis C virus antibodies

Cutaneous diseases can indicate the presence of hepatitis C virus (HCV) infection. The aim of this study was to analyse the frequency of cutaneous findings in HCV infection and HCV RNA positive cases in Turkey. Fifty consecutive patients positive for anti-HCV antibodies,negative controls, and patients positive and negative for HCV RNA were examined for any cutaneous findings that could be associated with HCV infection. The risk of infected patients developing cutaneous finding was higher than for non-infected individuals. Only pruritus showed a statistically significant difference in separate assessment of cutaneous symptoms. There were no differences in cutaneous findings in HCV RNA positive and negative cases. The risk of developing a dermatological finding, especially pruritus, was increased in HCV infection.However, because the number of patients in this study was too low to allow statistical evaluation of the prevalence of dermatological symptoms and diseases, multicentre studies including large numbers of patients are needed.     

Sporotrichosis in Queensland: a review of 37 cases at the Royal Brisbane Hospital.

Thirty-seven cases of sporotrichosis, seen at the Royal Brisbane Hospital from 1965 to 1977, were reviewed. Twenty-eight of the patients were male. The Youngest was 11 and the oldest 80 years. Only four patients has the cutaneous lymphatic variety of sporotrichosis—the others had the localised cutaneous type. There were not cases of systemic sporotrichosis. The lesions in most patients were on the upper limb—mainly the forearm and hand. There was a variety of clinical appearances of the lesions. The most common being ulcerated lesions and verrucous plaques. Confirmation of diagnosis was by positive culture from scrapings or biopsy specimen and/or typical histology. Twenty-four patients were treated with potassium iodide mixture and 11 had the lesions removed surgically. Of the 18 patients followed up, 17 were considered cured.     

Unusual clinical variants of cutaneous leishmaniasis in Sicily

Background  The term "leishmaniasis" defines a group of vector-borne diseases caused by species of the genus Leishmania and characterized by a spectrum of clinical manifestations. Parasite properties (infectivity, pathogenicity, virulence), host factors, and host responses regulate heterogeneous disease expression. Sicily is one of the major islands of the Mediterranean Basin and is considered to be a hypo-endemic area for cutaneous leishmaniasis. Leishmania infantum is the most common species on the island.
Methods  Fifty patients (both sexes and different ages) with lesions clinically suggestive of cutaneous leishmaniasis were recorded over a 1-year period. The diagnosis was based on positive slit-skin smear and histopathologic studies when needed. Polymerase chain reaction (PCR) was performed as test confirmation.
Results  Twenty-five patients had typical solitary lesions of cutaneous leishmaniasis. Multiple lesions were present in five patients. In 20 patients, the lesions were very unusual, including erysipeloid, zosteriform, and lupoid leishmaniasis. The results of Leishmania isoenzyme characterization identified Leishmania infantum as the species responsible for the 20 atypical cases.
Conclusion  The global number of cases of cutaneous leishmaniasis in Sicily has increased in recent years, and such increases can be explained, in part, by the fact that, in this region, sandflies are present during a large part of the year. This is a result of the climatic variation in recent years (increasing temperature and humidity). There has also been an increase in the number of new and rare variants of cutaneous leishmaniasis. A knowledge of the unusual clinical variants of cutaneous leishmaniasis, as well as classical forms, allows early detection.     

Lymphomatoid papulosis type A: clinical, morphologic, and immunophenotypic study

Background Lymphomatoid papulosis (LyP) is a cutaneous clonal or polyclonal Ki-1 + T-cell lymphoproliferative disorder, morphologically resembling Ki-1 + anaplastic large cell lymphomas (Ki-1 + ALCL) or Hodgkin's disease (HD). Lymphomatoid papulosis usually has a characteristic benign clinical course with remissions and relapses of the cutaneous eruptions. Methods The authors studied three patients with LyP. in each case the diagnosis was established based on the typical clinical history and presentation of the cutaneous lesions as well as the morphologic and immunophenotypic findings. Results in all three cases the skin biopsies showed a polymorphic, nonepidermotropic, dermal lymphocytic infiltrate, composed of small lymphocytes and fewer large, atypical cells. The large ceils were positive for the activation markers CD30 (Ki-1) and CD45R (leukocyte common antigen), and were negative for the HD marker CD15 (Leu Ml). Conclusions In most cases, LyP can be distinguished from Ki-1 + ALCL and HD on the basis of clinical, morphologic, and/or immunophenotypic findings. We emphasize the importance of the recognition of LyP as a clinicopathologic entity and the awareness of dermatologists, oncoiogists, and surgical pathologists in differentiating LyP from other primary cutaneous Ki-1 + lymphoproliferative disorders (Ki-1 + ALCL and HD). The prognosis of cutaneous Ki-1 + ALCL and HD is usually different from LyP and requires a different therapeutic approach.     

The T cell phenotypes in the lesion of patients with cutaneous leishmaniasis

Immunohistological analysis of the lesions of patients with cutaneous leishmaniasis showed that the OKT8 positive/cytotoxic T suppressor lymphocyte was the predominant cell in the mononuclear cell infiltrate. These patients were nor immunocompromised, had normal cellular immune functions and had developed specific cellular immunity to the infecting parasite, Leishmania tropica major (L. major). These findings support the contention that in patients with cutaneous leishmaniasis inappropriate sensitization of T suppressor lymphocytes occurs, which may, by inhibiting the positive inducer signals of T helper Lymphocytes, account for the chronicity of these lesions.     

Takayasu's disease with cutaneous involvement

Takayasu's arteritis (TA) is a chronic inflammatory and fibrosing arteriopathy that can also involve cutaneous vessels. The disease typically presents with a prepulseless phase that overlaps or is followed by the characteristic pulseless stage. In both phases of TA, cutaneous manifestations may be present. Lesions considered to be 'specifically' associated with TA have been described most frequently simulating erythema nodosum, erythema induratum and pyoderma gangrenosum. We report 2 Caucasian patients with TA and nodular cutaneous lesions. Nine skin biopsies from these patients were studied. A necrotizing vasculitis was present in 5 biopsies. We review those patients with TA and well-documented cutaneous manifestations in the English literature, with special interest in nodular lesions, the most frequent cutaneous manifestation of TA in Caucasian patients. Biopsies from lesions with similar morphology frequently show different histological findings.     

Cutaneous manifestations in childhood staphylococcal sepsis

In this article, the clinical and laboratory findings of six (15%) cases of cutaneous manifestations of 39 patients with sepsis caused by Staphylococcus aureus (S. aureus) were reviewed retrospectively. Our purpose was to determine the cutaneous manifestations in patients with sepsis caused by S. aureus. In our study, four patients had maculopapular and/or petechial/purpuric rashes, and two had erythematous lesions (one of them also had pustular lesions, and the other had furuncles). Aside from these, all patients had one or more systemic involvement such as bronchopneumonia, arthritis, osteomyelitis, or cardiac involvement. In conclusion, our findings suggest that there are no skin findings specific to staphylococcal sepsis and that pulmonary infections appear to have a high correlation with cutaneous findings, because all of our patients had evidence of bronchopneumonia. The mortality of staphylococcal sepsis associated with cutaneous findings appears to be high.     

Cutaneous polyarteritis nodosa: a clinical and histopathological study of 20 cases

Twenty cases diagnosed as cutaneous polyarteritis nodosa (CPN) and confirmed by skin biopsy over the last 17 years were reviewed in our department. Based upon their clinical features, laboratory findings, and long-term observation of the disease course, they were divided into three groups. 1) Group 1 comprised 16 cases which were classified as the mild cutaneous form. The disease was confined to the skin with occasional involvement of peripheral nerves and skeletal muscles of the affected extremity. They generally followed a benign course. 2) Group 2 comprised 2 cases classified as the severe form. Despite severe clinical manifestations and several abnormal laboratory findings, the disease was limited to the skin, muscles, and peripheral nerves without any visceral involvement over follow-up periods of 11 years and 5 years, respectively. 3) Group 3 comprised 2 cases of the progressive form; in these the disease had begun with a cutaneous lesion and progressed to the systemic form after 19 and 18 year periods of recurrent episodes of cutaneous lesions, respectively. One died of gastrointestinal bleeding. In group 3, serum antinuclear antibodies and rheumatoid factor were positive. The autoimmune mechanism seems to play a role in this group. It is clear from the results of this study that not all patients whose vasculitic lesions are apparently limited to the skin remain in a benign course. Long-term follow-up is essential.     

Clinico-epidemiologic forms of cutaneous leishmaniasis in Tunisia

From an analysis of 1,546 cases of cutaneous leishmaniasis collected throughout Tunisia three clinico-epidemiological forms could be determined. These forms are due to three different species of Leishmania and are observed in different geographical areas. Sporadic cutaneous leishmaniasis (SCL), 63 cases. This form is found in Northern Tunisia, in known foci of Kala-azar. 96% of the patients have a single, small, ulcerated and crusty lesion on the face surrounded by an important zone of infiltration. Amastigotes are less than 4 microns in diameter, and it is very difficult to maintain the parasites in cultures. This form is probably due to Leishmania infantum, as has been demonstrated in Algeria in a similar form evolving in the same biotope as the Tunisian form. The vector and reservoirs of SCL are unknown. Zoonotic cutaneous leishmaniasis (ZCL), 1,412 cases. The disease is epidemic in Central and Southern Tunisia. The lesions are multiple; they affect the limbs more frequently than the face and heal in less than 8 months. They are polymorphous, usually large and superinfected. There is a seasonal occurrence of the outbreaks (summer and autumn). Amastigotes are large (4 to 6.5 microns in diameter) and the parasites easily grow in cultures. This form is caused by Leishmania major, and its vector is Phlebotomus papatasi. Three species of rodents harbour the parasite. Anthroponotic cutaneous leishmaniasis (ACL), 71 cases. This form is endemic in South-Eastern Tunisia. 70% of the patients present with single lesions, one half of which affect the face. Dry and proliferating lesions are the most frequent.(ABSTRACT TRUNCATED AT 250 WORDS)