Disseminated cutaneous histoplasmosis in an immunocompetent adult

Histoplasmosis, a systemic mycosis caused by the dimorphic fungus Histoplasma capsulatum var capsulatum and Histoplasma capsulatum var duboisii is endemic to many parts of the world. The clinical manifestations range from acute or chronic pulmonary infection to a progressive disseminated disease. After initial exposure to the fungus, the infection is self-limited and restricted to the lungs in 99% of healthy individuals. The remaining 1%, however, progress to either disseminated or chronic disease involving the lungs, liver, spleen, lymph nodes, bone marrow or rarely, the skin and mucous membranes. Mucocutaneous histoplasmosis is frequently reported in patients with acquired immune deficiency syndrome (AIDS), but it is rare in immunocompetent hosts. A 60-year-old male presented with asymptomatic swelling of the hard palate and crusted papules and nodules over the extremities, face and trunk. Clinically, the diagnoses of cutaneous cryptococcosis versus histoplasmosis was considered in this patient. A chest X-ray revealed hilar lymphadenopathy. Enzyme-linked immunosorbent assay (ELISA) for human immunodeficiency virus (HIV) was nonreactive. Skin biopsy revealed multiple tiny intracellular round yeast forms with a halo in the mid-dermis. Culture of the skin biopsy in Sabouraud's dextrose agar showed colonies of Histoplasma capsulatum. Despite an investigation including no evidence of underlying immunosuppression was found, he was started on IV amphotericin-B (0.5 mg/kg/day). However, the patient succumbed to his disease 2 days after presentation. We report a rare case of disseminated cutaneous histoplasmosis in an immunocompetent individual.     

Micosis sistémicas en pacientes con virus de la inmunodeficiencia humana/sida

Histoplasmosis is a systemic infection caused by the dimorphic fungus Histoplasma capsulatum. In immunocompromised patients, primary pulmonary infection can spread to the skin and meninges. Clinical manifestations appear in patients with a CD4⁺ lymphocyte count of less than 150 cells/μL.Coccidioidomycosis is a systemic mycosis caused by Coccidioides immitis and Coccidioides posadasii. It can present as diffuse pulmonary disease or as a disseminated form primarily affecting the central nervous system, the bones, and the skin.Cryptococcosis is caused by Cryptococcus neoformans (var. neoformans and var. grubii) and Cryptococcus gattii, which are members of the Cryptococcus species complex and have 5 serotypes: A, B, C, D, and AD. It is a common opportunistic infection in patients with human immunodeficiency virus (HIV)/AIDS, even those receiving antiretroviral therapy.Histopathologic examination and culture of samples from any suspicious lesions are essential for the correct diagnosis of systemic fungal infections in patients with HIV/AIDS.     

Disseminated cutaneous-only histoplasmosis in a patient with AIDS

Histoplasmosis is an opportunistic fungal infection that occurs predominantly in immunocompromised patients. Cutaneous lesions in histoplasmosis are rare and typically occur in the absence of extra-cutaneous manifestations. We present a rare case of disseminated cutaneous-only histoplasmosis in a patient with recently diagnosed AIDS.     

Disseminated histoplasmosis detected by lingual and tonsillar erosions in an immunocompetent patient

BACKGROUND: Histioplasmosis is a usually asymptomatic fungal infection. In the immunocompetent patient, it leads to chronic disseminated infection. Mucosal involvement is common and can provide the diagnosis. CASE REPORT: A metropolitan Frenchman with a history of alcoholism and smoking and living in Guyana consulted for lingual and tonsil erosion. Squamous cell carcinoma was suspected but not confirmed at pathology. The patient had a bi-apical infiltration on the chest x-ray and was treated empirically for tuberculosis. The diagnosis of histoplasmosis was reached when rare Histoplasma capsulatum were evidenced from a buccal swab. Itraconazole led to cure in 6 months. DISCUSSION: This case illustrates the importance of mucosal signs in the diagnosis of disseminated histoplasmosis in immunocompetent subjects. Histoplasmosis is rarely the cause of active infection in immunocompetent subjects. In these patients, the fungal infection generally progresses to chronic dissemination. Mucosal signs are frequent in this form but are rare in case of cutaneous histoplasmosis. Itraconazole (200 mg/d) is indicated for 6 months.     

Oral histoplasmosis after radiation therapy for laryngeal squamous cell carcinoma

Histoplasmosis is a usually asymptomatic deep fungal infection of tropical origin with respiratory entry and possible oral, pharyngeal, or metastatic localization. The condition represents an important imported systemic mycosis with oral involvement. We report the case of a patient who developed an oropharyngeal reactivation of a latent Histoplasma infection after receiving local antitumoral radiation therapy of the neck. H capsulatum was shown to be present in the lesion by both histopathology and staining, and was deduced to be the causative organism of the disease.     

Phase I/II study of the oral retinoid X receptor agonist bexarotene in Japanese patients with cutaneous T‐cell lymphomas

Safety, tolerability, pharmacokinetics and efficacy of bexarotene, a novel retinoid X receptor (RXR)‐selective retinoid, were evaluated in Japanese patients with stage IIB–IVB and relapsed/refractory stage IB–IIA cutaneous T‐cell lymphomas (CTCL). This study was conducted as a multicenter, open‐label, historically controlled, single‐arm phase I/II study. Bexarotene was p.o. administrated once daily at a dose of 300 mg/m² for 24 weeks in 13 patients, following an evaluation of safety and tolerability for 4 weeks at a dose of 150 mg/m² in three patients. Eight of 13 patients (61.5%) with an initial dose of 300 mg/m² met the response criteria using the modified severity‐weighted assessment tool (mSWAT) at 24 weeks or discontinuation. Dose‐limiting toxic effects (DLT) were present in four of 13 patients (31%) at a dose of 300 mg/m²: two neutropenia, one abnormal hepatic function and one hypertriglyceridemia. No DLT was observed in patients received 150 mg/m² bexarotene. In the 13 patients at 300 mg/m², common drug‐related adverse events (AE) included hypothyroidism (92%), hypercholesterolemia (77%), leukopenia or neutropenia (39%), nasopharyngitis or anemia (31%). The treatment‐related grade 3 AE included hypertriglyceridemia (4/16 patients, 25%), increased alanine aminotransferase, increased aspartate aminotransferase, dyslipidaemia, leukopenia and neutropenia (1/16 patients, 6%), and one of 16 patients experienced grade 4 hypertriglyceridemia. No patients discontinued bexarotene due to the AE during the study, but dose reduction or suspension was required. Bexarotene was shown to be well tolerated at 300 mg/m² once daily and effective in Japanese patients with CTCL.     

Disseminated histoplasmosis in an AIDS patient treated with itraconazole.

A patient with AIDS presented with a fever, shortness of breath and a productive cough. A provisional diagnosis of Pneumocystis carinii pneumonia was made; however, blood cultures and bone marrow examination revealed disseminated infection with Histoplasmosis capsulatum. This was treated by itraconazole with initial success, but the patient relapsed while on maintenance therapy.     

Cutaneous ulcer in an immunosuppressed patient with adult onset Still's disease: primary cutaneous histoplasmosis?

Histoplasmosis is caused by the dimorphic fungus Histoplasma capsulatum.Primary infection occurs through inhalation of spores from the air. Immunocompetent individuals are usually asymptomatic, but may develop pulmonary disease. Immunocompromised patients tend to present systemic histoplasmosis with cutaneous lesions occurring by secondary invasion. In this case report, we describe a probable primary cutaneous histoplasmosis (PCH) in a patient with adult onset Still''s disease under immunosuppression.     

Normal sweat secretion rate in patients with alopecia areata

We have examined sweat secretion rates in 22 patients with alopecia areata, and 22 age- and sex matched controls. Mean sweat rate on the forearm in patients with alopecia areata was 20 mg/cm² per h (95% confidence limits 15–25 mg/cm² per h), and in controls was 24.1 mg/cm² per h (95% confidence limits 19.1–29.1 mg/cm² per h). Sweat secretion was higher in males than females in both the disease and control groups (27.8 mg/cm² per h [95% confidence limits 21.3–34.3 mg/cm² per h], compared with 18.08 mg/cm² per h [95% confidence limits 14.63-21.6 mg/cm²]; P > 0.01). Our results confirm the previously reported sex difference in sweat secretion rate, and demonstrate that there is no statistically significant difference between patients with alopecia areata and controls. We discuss our results in the light of a previous report claiming that patients with alopecia areata have reduced rates of cholinergic-induced sweating.     

How much skin protection cream is actually applied in the workplace? Determination of dose per skin surface area in nurses

Background. Skin protection creams (PCs) are used in the occupational setting to prevent irritant hand dermatitis. However, so far, the actual amounts of PC applied and the resulting dose per area unit on hands at work have not been a matter of systematic investigation. The quantities used in experimental studies investigating the efficacy of PCs range between 4 and 25 mg/cm². Objectives. To develop a practical and accurate method to analyse the actual consumed quantities of PCs at workplaces in relation to hand surface area. Methods. Thirty‐one hospital nurses without hand eczema were provided with a sample PC in special monitoring tubes with Medication Event Monitoring Systems (MEMS TrackCaps^®; Aardex Ltd, Zug, Switzerland), and used the product over 5 working days as usual. The consumption was calculated by weighing of the tubes and analysis of the application frequency, and related to the individual calculated hand surface area. Results. The mean PC dose applied was 0.97 ± 0.6 mg/cm². Conclusions. The amounts of PC applied by hospital nurses were significantly lower than the amounts that have been used in experimental studies. The method appears to be suitable for use in different in occupational settings. Further investigations are needed to gain realistic insights into consumers' attitudes regarding PCs.     

Skin lesions in histoplasmosis

Histoplasmosis is a granulomatous infection caused by Histoplasma capsulatum, a dimorphic fungus. It is distributed worldwide and prevalent in certain regions of North and Central America. Pulmonary involvement is the most common clinical presentation. Cutaneous manifestations are reported to occur in 10% to 25% of AIDS patients with disseminated histoplasmosis. The skin lesions are polymorphic papules, plaques with or without crusts, pustules, nodules, mucosal ulcers, erosions, punched out ulcers, lesions resembling molluscum contagiosum, acneiform eruptions, erythematosus papules and keratotic plaques, purpuric lesions, and localized and generalized vegetant forms of dermatitis, sometimes an eruption similar to rosacea, keratotic papules with transepidermal elimination, polymorphous erythema, erythroderma syndromes, pyoderma gangrenosum, panniculitis, diffuse hyperpigmentation, abscesses, and cellulitis.     

Erythema nodosum. A review

Erythema nodosum is not an uncommon dermatologic entity. Sarcoidosis and streptococcal infection have become the two most common causes, while tuberculosis was the predominant etiology prior to the use of isoniazid. Histoplasmosis and coccidioidomycosis are two important geographic considerations. Laboratory tests should include a PPD test, chest x-ray, throat culture for beta-streptococcus, and ASO titer determination as a minimum. Symptomatic treatment remains unsatisfactory in many cases, although recent success has been reported with oral potassium iodide.     

Concentrations of nitrogen mustard in the air during topical treatment of patients with mycosis fungoides

Acute and chronic side-effects have been reported during topical treatment of mycosis fungoides with nitrogen mustard (HN2). In order to estimate the risk for the nurse applying topical HN2, the concentration of HN2 in the air during treatment was measured. Air samples were obtained before, and during the 20-min treatment period close to the nurse and patient, and continuously at a distance of 1 m from the patient. The mean concentration of HN2 in the air during treatment was 0.036 mg/m³. Immediately after treatment the concentration dropped to 0.004 mg/m³. The mean cumulative concentration in the room during the 3½h of the experiment was 0.012 mg/m³. If the MAC (maximal allowable concentration) value of 0.05 mg/m³ for the comparable sulphur mustard is used as a guideline, then with a treatment procedure of 20 min this level is not exceeded. Nevertheless, it is important to minimize the exposure of nursing staff to HN2.     

Histoplasmosis

Histoplasmosis is caused by Histoplasma capsulatum, a dimorphic fungus. Because histoplasmosis is usually a self-limited disease in the majority of cases, treatment often is not needed in the normal host. However, severe cases of acute pulmonary histoplasmosis require therapy. Amphotericin B is considered the treatment of choice.     

Refractory Kasabach–Merritt phenomenon successfully treated with sirolimus,and a mini‐review of the published work

Kasabach–Merritt phenomenon (KMP) is a rare and life‐threatening disease involving a vascular tumor combined with severe consumptive coagulopathy. We present for the first time a case of KMP with the vascular tumor involving two anatomical sites; the patient failed to respond to steroids and vincristine. Following sirolimus therapy at a dose of 0.8 mg/m² twice daily, the lesions shrank and the platelet count improved and remained normal 4 months after initial therapy. Current treatments for KMP are not particularly effective. Sirolimus at 0.8 mg/m² per dose, administrated twice daily, appears to be a safe and effective management option. It appears to be an interesting therapeutic option in refractory KMP, but the time to response is variable.     

Leg ulcers caused by deep mycotic infection

Leg ulcers causing deep mycosis following fungi are encountered in temperate and tropical climates. They are usually asymetrical, and are located over trauma-prone areas of the legs. The ulcers are usually asympatomatic and insidious at onset. They are often confined to certain geographic regions; sporadic cases have, however, been seen elsewhere. The common deep mycoses causing leg ulcers are mycetoma, sporotrichosis, chromomycosis, and blastomycosis. Histoplasmosis and lobomycosis may occasionally produce bizarre leg ulcers. The causative fungus in them may either be identified through smears/histopathologic sections or on culture.     

The relation between sunscreen layer thickness and vitamin D production after ultraviolet B exposure: a randomized clinical trial

Background Sunscreens absorb ultraviolet B (UVB) and it is a major concern that sunscreen use may lead to vitamin D deficiency. Objectives To investigate the relation between the amount of sunscreen applied and the vitamin D serum level in humans after UVB exposure under controlled conditions. Methods Thirty‐seven healthy volunteers with fair skin types were randomized to receive an inorganic sunscreen with sun protection factor (SPF) 8 of 0 mg cm^?2, 0·5 mg cm^?2, 1 mg cm^?2, 1·5 mg cm^?2, or 2 mg cm^?2 thickness on the upper body, approximately 25% of the body area. Participants were irradiated with a fixed UVB dose of 3 standard erythema doses 20 min after sunscreen application. This procedure was repeated four times with a 2‐ to 3‐day interval. Blood samples were drawn before the first irradiation and 3 days after the last to determine the serum vitamin D level expressed as 25‐hydroxyvitamin D₃ [25(OH)D]. Results The vitamin D serum level increased in an exponential manner with decreasing thickness of sunscreen layer in response to UVB exposure. For all thicknesses of sunscreen, the level of 25(OH)D increased significantly after irradiation (P < 0·05), except for the group treated with 2 mg cm^?2, in which the increase in 25(OH)D was not statistically significant (P = 0·16). Conclusions Vitamin D production increases exponentially when thinner sunscreen layers than recommended are applied (< 2 mg cm^?2). When the amount of sunscreen and SPF advised by the World Health Organization are used, vitamin D production may be abolished. Re‐evaluation of sun‐protection strategies could be warranted.     

PEMPHIGUS FOLIACEUS AND NON-HODGKIN'S LYMPHOMA

A 56-year-olcl Iraqi woman presented to her general practitioner with an erythematous scaly eruption on the left ear. An initial diagnosis of otitis externa was made and a 7-day-course of penicillin commenced. Three days later, the patient returned complaining of abdominal pain and diarrhea. Examination of the abdomen revealed a large mass. Subsequent investigation with computerized tomography (CT) scanning showed a large paraaortic mass, fine needle biopsy of which showed a diffuse non-Hodgkins lymphoma. The majority of the cells were small follicle center cells with clear nuclei that stained positively for B-lymphocyte antigens (L26, MB2). Bone marrow biopsy showed focal paratrabecular deposition of non-Hodgkins lymphoma cells of a similar nature to those in the paraaortic node. The patient was started on a monthly regimen of chlorambucil 10 mg daily with prednlsolone 40 mg daily for the first 10 days and allopurinol, 200 mg daily. Fourteen days after completing the first monthly course of treatment the patient developed a generalized eruption. This was initially attributed to her allopurinol therapy, which was discontinued. The patient was given a second 10-day course of prednisolone and chlorambucil, at the end of which the eruption had almost completely resolved. Within 9 days the eruption recurred and the patient complained of red eyes. Examination of the skin showed scattered urticated plaques with peripheral vesiculation on the trunk and annular urticated lesions without vesiculation on the legs. A scaly erythematous eruption was also noted on the left ear (Fig. 1). The hemoglobin was 10.9 g/dL, with a normochromic, normocytic picture with rouleaux formation on the blood smear. The WBC was 7.9, with lymphopenia of 1.0 (normal range 1.5–4.0 × 10^?9). Lymphocyte subset analysis showed decreased numbers of cytotoxic/suppressor T cells (0.16 × 10^?9; normal range 0.28–1.35 × 10^?9). The helper T cell num-bers and the platelet count were normal. The erythrocyte sedimentation rate (ESR) was 102. Urea and electrolytes, and liver function tests were normal. Total protein was 85 g/L (normal range 60–80 g/L). Serum electrophoresis showed an acute phase response with increased IgA of 6.0 g/L (normal range 0.8–4.0 g/L). Routine hematoxylin and eosin stain of a biopsy of an urticated vesicular lesion on the trunk and from the erythematous lesion on the ear showed small subcorneal blisters beginning to form that contained eosinophils together with eosinophilic spongiosis. Direct immunofluorescence of perilesional uninvolved skin showed intercellular deposition of igG and C3 typical of pemphigus. Indirect immunoflu-orescence revealed circulating IgG intercellular antibodies to atitre of 1:160. The patient was treated with prednisolone, 80 mg daily. The previous regimen of chlorambucil, 10 days each month, was continued and daily allopurinol recommenced. This was followed by resolution of the eruption, the eruption on the ear being the last area to resolve. Ten-day courses of chlorambucil were given monthly for a further 7 months, following which, a course of palliative radiotherapy was given to the paraaortic nodes. Although repeat CT scan after 3 months of chemotherapy showed a dramatic reduction in the paraaortic mass, this has remained unchanged 1 year later.     

Relationship between sun‐protection factor and application thickness in high‐performance sunscreen: double application of sunscreen is recommended

Background. High‐performance sunscreen protects both healthy consumers and photosensitive patients from strong ultraviolet (UV) exposure. The sun‐protection factor (SPF), which indicates the efficacy of UV protection, is determined using a prescribed sunscreen application thickness of 2.0 mg/cm². Therefore, users should apply at least 2.0 mg/cm² of sunscreen to obtain the level of UV protection expected from a product. In most cases, however, users apply insufficient amounts of sunscreen. Aim. To determine the amount of sunscreen applied under specific conditions, and the relationship between application thickness and SPF value in high‐performance sunscreen. Methods. The amount of applied sunscreen was calculated under practical conditions and conditions that directed a double application. The SPF values of high‐performance sunscreen applied at three thicknesses (2.0, 1.0 and 0.5 mg/cm²) were determined according to the international SPF testing method. Results. The relationship between SPF value and application thickness correlated in a logarithmic curve. The mean application thickness under practical conditions was approximately 1 mg/cm², and directing subjects to use a double application increased the application thickness to nearly 2 mg/cm². Conclusion. Encouraging a double application of sunscreen will help users apply products at a thickness sufficient to achieve expected SPF efficacy. We recommend that guidance on double application of sunscreen should be posted in public locations where sunscreen is likely to be in use.     

Patch test concentrations (doses in mg/cm2 ) for the 12 non-mix fragrance substances regulated by European legislation

Background. According to EU legislation, 26 fragrance substance allergens must be labelled on cosmetic products. For 12 of them, the optimal patch test concentration/dose has not been evaluated. Objectives. To establish the optimal patch test doses in mg/cm² for the 12 fragrance substances that are not included in fragrance mix I or II in the European baseline patch test series. Materials and Methods. Patch testing with the 12 fragrance substances was performed in a stepwise manner encompassing up to five rounds in at least 100 dermatitis patients for each round. Before patch testing, an individual maximum concentration/dose was determined for each fragrance substance. Results. The predetermined maximum patch test concentrations/doses could be tested for all 12 fragrance substances, with no observable adverse reactions being noted. Conclusions. For each fragrance substance investigated, it is recommended that half of the maximum patch test dose (mg/cm²) be used for aimed and screening patch testing.