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Targetoid “erythema nodosum leprosum” as a first presentation of multibacillary leprosy
Syphilis and coinfection with HIV: Atypical skin lesion and prozone effect
(Poster reference number 4873)
Luciana Klein, MD, Fundac¸~ao Osvaldo Cruz- FIOCRUZ, Rio de Janeiro, Brazil; Carla Giacomo, MD, Fundac¸~ao Osvaldo Cruz- FIOCRUZ, Rio de janeiro, Brazil; Fernanada Pires, MD, Fundac¸~ao Osvaldo Cruz- FIOCRUZ, Rio de Janeiro, Brazil; Jose Augusto Nery, MD, Fundac¸~ao Osvaldo Cruz- FIOCRUZ, Rio de Janeiro, Brazil Background: Syphilis is a chronic contagious disease, known in Europe since the final of XV century. Caused by Treponema pallidum, a bacteria first identified in 1905 by Schaudinn and Hoffmann. Trasmitted by sexual relation with no protection, transplacental and blood transfusion, and direct contact with skin lesion of infected pacients. The diagnostic method largely applied for screening in Brazil is the Venereal Disease Lipid Reaction (VDRL), which is the most indicated by World Health Organization (WHO) among nontreponemal tests. Studies demonstrate that syphilis is the most associated venereal disease (VD) with the infection of HIV, and its incidence is 90 times bigger in this population. Prozone effect, occurs when a large amount of antibodies is present in tested serum. It will lead to false negative VDRL. The estimate number is 1% to 2% of all syphilis cases, and in HIV patients, this number increases to 7%. Case report: A 37-year-old man with a diagnosis of HIV infection in 2007 and antiretroviral treatment since 2008, presented with brownish macules in face and lower limbs for 6 months. No symptoms were associated. No history of genital ulcer. Brought a VDRL of 4 months ago that was negative. He was treated for leprosy for 12 months, three years ago. At the exam: brownish macules in face and legs only, with no alteration of sensitivity. A new VDRL was made, the result was negative. After this, a treponemal test was done and the dilution of the patient’s serum. The treponemal test was positive and VDRL postdilution positive (1/128). Conclusion: Syphilis is known as a condition that can imitates a large variety of diseases; therefore, unusual clinical manifestations can occur, especially when dealing with patients with HIV infection. In spite of nonspecific dermatologic aspects for syphilis, physicians must think about this possibility in patients with AIDS, because there is large association of these two diseases. When VDRL is negative, the investigation of cause must persist, and prozone effect must be suspected because this phenomenon is more often in cases of coinfection with HIV and syphilis. Treponemal tests should be requested to confirm the diagnoses as well as the dilution of the patient’s serum. Commercial support: None identified.
Targetoid ‘‘erythema nodosum leprosum’’ as a first presentation of multibacillary leprosy
(Poster reference number 4669)
Mahmoud Dessoukey, MD, Sheikh Khalifa Medical City-Cleveland Clinic, Abu Dhabi, United Arab Emirates; Ken Malanin, MD, Sheikh Khalifa Medical CityCleveland Clinic, Abu Dhabi, United Arab Emirates; Meera Al Adawi, MD, Sheikh Khalifa Medical City-Cleveland Clinic, Abu Dhabi, United Arab Emirates; Shaden Abdel Hadi, MD, Sheikh Khalifa Medical City-Cleveland Clinic, Abu Dhabi, United Arab Emirates Leprosy, a multiorgan mycobacterial disease, may be associated with type I and type II reactions. Type II reaction is also known as erythema nodosum leprosum (ENL). We report a 23-year-old, previously healthy woman from Indonesia who presented to the emergency room (ER) with high fever, fatigue, multiple joint pains and painful skin lesions on the face and extremities of 10 days duration. Prior to her visit to the ER, she has received amoxicillin clavulanate for 5 days and a single dose of azithromycin 500 mg. Skin examination revealed numerous, erythematous, targetlike nodules with central blistering and necrosis over the face and extremities. The initial clinical impression was erythema multiforme or Sweet syndrome with fever for investigation. Skin biopsy revealed marked granulomatous inflammation in the dermis and subcutaneous fat, centered on adnexal structures. The infiltrate is composed of foamy histiocytes, lepra cells, lymphocytes and plasma cells. There is also necrosis with a few neutrophils and nuclear dust. Fite stain revealed large numbers of acid fast bacilli within the lepra cells and histiocytes. Accordingly, the diagnosis of ENL with multibacilary leprosy was made. Treatment was initiated with multibacillary multidrug therapy together with prednisolone 40 mg/day. Patient became afebrile and the skin lesions cleared in 1 week. ENL is an acute reaction state in the chronic course of multibacillary leprosy. It occurs usually during or after antimycobacterial treatment. However, it has been rarely reported before starting treatment or as the first clinical manifestation of leprosy. In our patient, who lives in an endemic area of leprosy (Indonesia), ENL was the first recognizable manifestation of leprosy. Drugs such as fluoquinolones, ethinyestradiol, and stilbesterol have been described as a probable trigger of ENL. In the present case, ENL developed during treatment with amoxicillin clavulanate and azithromycin, suggesting a possible eliciting role of these medications. ENL, characteristically, presents as nodules over the face, arms. and legs. On the other hand, unusual clinical presentation such as targetoid, pustular, ulcerative-necrotic or bullous, may lead to misdiagnosis. We report a patient with ENL as a first manifestation of multibacillary leprosy characterized by unusual clinical presentation (targetoid, vesicular, and necrotic), possibly triggered by amoxicillin clavulanate or azithromycin. Commercial support: None identified.
Syphilitic elephantiasis of penis and scrotum
(Poster reference number 5236)
Nuria Latorre, Hospital General Universitario de Alicante, Alicante, Spain; Almudena Flavia Monteagudo, Hospital General Universitario de Alicante, Alicante, Spain; Jose Carlos Pascual, Hospital General Universitario de Alicante, Alicante, Spain; Laura Cuesta, Hospital General Universitario de Alicante, Alicante, Spain Case report: A 54-year-old white man presented with a 4 day-long history of fever (388C), penoscrotal edema, and malaise. Clinical examination revealed a painless ulcer on the penis and painless enlargement of inguinal lymph nodes. Elephantiasis of the penis and scrotum was evident. Blood test examination was normal, except for an elevated erythrocyte sedimentation rate. Urine analysis was also normal. The patient recognized unprotected sexual contacts. Because of the clinical suspicion of syphilis, a serologic test was performed and resulted positive to FTA-abs with a RPR titer of 1/64. Serologic test for HIV was negative. Because the patient was allergic to penicillin, a 28-day course of doxycycline (100 mg twice a day) was started with rapid improvement of the symptoms.
Thermotherapy with the Alma Accent for the treatment of cutaneous leishmaniasis
(Poster reference number 5355)
Jennifer Ragi, MD, UMDNJ-Robert Wood Johnson Medical School, Somerset, NJ, United States; Amy Pappert, MD, UMDNJ-Robert Wood Johnson Medical School, Somerset, NJ, United States; David Milgraum, Tuoro College, New York, NY, United States; Sandy Milgraum, MD, UMDNJ-Robert Wood Johnson Medical School, Somerset, NJ, United States
Discussion: Syphilis is normally manifested 2 weeks after sexual exposure with the characteristic painless penile ulcer. If left untreated, the infection rapidly progresses to the secondary stage, which is characterized by the appearance of skin rashes that can mimic many other skin diseases. Systemic symptoms such as fever, headache, muscle ache, weight loss, and fatigue may also appear. Although enlargement of inguinal lymph nodes is often detected, penoscrotal elephantiasis is very rare. This manifestation probably appears as a result of the enlargement of the lymph nodes and lymphatic flow obstruction caused by the infection of the genitalia. The incidence of syphilis dramatically declined in the past, probably because of the AIDS prevention campaigns. Unfortunately, nowadays it can be considered as a resurgent disease. Because a misdiagnosis of this infection can have serious consequences for the patient, clinicians should be aware of the many manifestations of syphilis. Conclusion: We present a 54-year-old man with syphilitic elephantiasis of penis and scrotum, which is a very rare manifestation of this disease.
New World leishmaniasis is caused by a protozoan infection of Leishmania species found in Central and South America. It has a wide clinical spectrum ranging from cutaneous ulcers to disfiguring mucocutaneous disease or visceral disease which can be fatal. Treatment for New World cutaneous leishmaniasis (CL) is standard since untreated individuals can develop chronic ulcers, recidivant. lesion or mucocutaneous involvement. Current treatment with intravenous pentavalent antimony is expensive, difficult to obtain, and has numerous adverse effects. While intralesional injection of this medication has less systemic side effects, it is painful and often not preferred by patients. We present a detail case report with clinical images of a patient with Leishmania mexicana who was successfully treated with thermotherapy in an unconventional way. Generally, thermotherapy can be applied with warm water soaks, heating pads, or high-energy light waves. In 2003, the ThermoMed model 1.8 apparatus was approved by the US Food and Drug Administration (FDA) for the treatment of CL by applying radiofrequency heat with a bipolar probe to heat the infected tissue to 508C for 30 seconds. However, this apparatus is not readily available to most dermatologists. In this case report, the infection was successfully treated with the same dose of heat delivered by bipolar radio frequency from the Alma Accent, a cosmetic device. This device is not currently FDA approved for treatment of CL. The authors want to highlight that topical treatment in New World CL is not recommended except in cases of infection with L mexicana where the risk of progression to mucosal leishmaniasis is nearly nonexistent. The mechanism by which thermotherapy successfully cures CL is still unknown. This case report reminds dermatologists that treatment with thermotherapy for CL is efficacious.
Commercial support: None identified.
Commercial support: None identified.
AB114
J AM ACAD DERMATOL
APRIL 2012
(Poster reference number 4873)
Luciana Klein, MD, Fundac¸~ao Osvaldo Cruz- FIOCRUZ, Rio de Janeiro, Brazil; Carla Giacomo, MD, Fundac¸~ao Osvaldo Cruz- FIOCRUZ, Rio de janeiro, Brazil; Fernanada Pires, MD, Fundac¸~ao Osvaldo Cruz- FIOCRUZ, Rio de Janeiro, Brazil; Jose Augusto Nery, MD, Fundac¸~ao Osvaldo Cruz- FIOCRUZ, Rio de Janeiro, Brazil Background: Syphilis is a chronic contagious disease, known in Europe since the final of XV century. Caused by Treponema pallidum, a bacteria first identified in 1905 by Schaudinn and Hoffmann. Trasmitted by sexual relation with no protection, transplacental and blood transfusion, and direct contact with skin lesion of infected pacients. The diagnostic method largely applied for screening in Brazil is the Venereal Disease Lipid Reaction (VDRL), which is the most indicated by World Health Organization (WHO) among nontreponemal tests. Studies demonstrate that syphilis is the most associated venereal disease (VD) with the infection of HIV, and its incidence is 90 times bigger in this population. Prozone effect, occurs when a large amount of antibodies is present in tested serum. It will lead to false negative VDRL. The estimate number is 1% to 2% of all syphilis cases, and in HIV patients, this number increases to 7%. Case report: A 37-year-old man with a diagnosis of HIV infection in 2007 and antiretroviral treatment since 2008, presented with brownish macules in face and lower limbs for 6 months. No symptoms were associated. No history of genital ulcer. Brought a VDRL of 4 months ago that was negative. He was treated for leprosy for 12 months, three years ago. At the exam: brownish macules in face and legs only, with no alteration of sensitivity. A new VDRL was made, the result was negative. After this, a treponemal test was done and the dilution of the patient’s serum. The treponemal test was positive and VDRL postdilution positive (1/128). Conclusion: Syphilis is known as a condition that can imitates a large variety of diseases; therefore, unusual clinical manifestations can occur, especially when dealing with patients with HIV infection. In spite of nonspecific dermatologic aspects for syphilis, physicians must think about this possibility in patients with AIDS, because there is large association of these two diseases. When VDRL is negative, the investigation of cause must persist, and prozone effect must be suspected because this phenomenon is more often in cases of coinfection with HIV and syphilis. Treponemal tests should be requested to confirm the diagnoses as well as the dilution of the patient’s serum. Commercial support: None identified.
Targetoid ‘‘erythema nodosum leprosum’’ as a first presentation of multibacillary leprosy
(Poster reference number 4669)
Mahmoud Dessoukey, MD, Sheikh Khalifa Medical City-Cleveland Clinic, Abu Dhabi, United Arab Emirates; Ken Malanin, MD, Sheikh Khalifa Medical CityCleveland Clinic, Abu Dhabi, United Arab Emirates; Meera Al Adawi, MD, Sheikh Khalifa Medical City-Cleveland Clinic, Abu Dhabi, United Arab Emirates; Shaden Abdel Hadi, MD, Sheikh Khalifa Medical City-Cleveland Clinic, Abu Dhabi, United Arab Emirates Leprosy, a multiorgan mycobacterial disease, may be associated with type I and type II reactions. Type II reaction is also known as erythema nodosum leprosum (ENL). We report a 23-year-old, previously healthy woman from Indonesia who presented to the emergency room (ER) with high fever, fatigue, multiple joint pains and painful skin lesions on the face and extremities of 10 days duration. Prior to her visit to the ER, she has received amoxicillin clavulanate for 5 days and a single dose of azithromycin 500 mg. Skin examination revealed numerous, erythematous, targetlike nodules with central blistering and necrosis over the face and extremities. The initial clinical impression was erythema multiforme or Sweet syndrome with fever for investigation. Skin biopsy revealed marked granulomatous inflammation in the dermis and subcutaneous fat, centered on adnexal structures. The infiltrate is composed of foamy histiocytes, lepra cells, lymphocytes and plasma cells. There is also necrosis with a few neutrophils and nuclear dust. Fite stain revealed large numbers of acid fast bacilli within the lepra cells and histiocytes. Accordingly, the diagnosis of ENL with multibacilary leprosy was made. Treatment was initiated with multibacillary multidrug therapy together with prednisolone 40 mg/day. Patient became afebrile and the skin lesions cleared in 1 week. ENL is an acute reaction state in the chronic course of multibacillary leprosy. It occurs usually during or after antimycobacterial treatment. However, it has been rarely reported before starting treatment or as the first clinical manifestation of leprosy. In our patient, who lives in an endemic area of leprosy (Indonesia), ENL was the first recognizable manifestation of leprosy. Drugs such as fluoquinolones, ethinyestradiol, and stilbesterol have been described as a probable trigger of ENL. In the present case, ENL developed during treatment with amoxicillin clavulanate and azithromycin, suggesting a possible eliciting role of these medications. ENL, characteristically, presents as nodules over the face, arms. and legs. On the other hand, unusual clinical presentation such as targetoid, pustular, ulcerative-necrotic or bullous, may lead to misdiagnosis. We report a patient with ENL as a first manifestation of multibacillary leprosy characterized by unusual clinical presentation (targetoid, vesicular, and necrotic), possibly triggered by amoxicillin clavulanate or azithromycin. Commercial support: None identified.
Syphilitic elephantiasis of penis and scrotum
(Poster reference number 5236)
Nuria Latorre, Hospital General Universitario de Alicante, Alicante, Spain; Almudena Flavia Monteagudo, Hospital General Universitario de Alicante, Alicante, Spain; Jose Carlos Pascual, Hospital General Universitario de Alicante, Alicante, Spain; Laura Cuesta, Hospital General Universitario de Alicante, Alicante, Spain Case report: A 54-year-old white man presented with a 4 day-long history of fever (388C), penoscrotal edema, and malaise. Clinical examination revealed a painless ulcer on the penis and painless enlargement of inguinal lymph nodes. Elephantiasis of the penis and scrotum was evident. Blood test examination was normal, except for an elevated erythrocyte sedimentation rate. Urine analysis was also normal. The patient recognized unprotected sexual contacts. Because of the clinical suspicion of syphilis, a serologic test was performed and resulted positive to FTA-abs with a RPR titer of 1/64. Serologic test for HIV was negative. Because the patient was allergic to penicillin, a 28-day course of doxycycline (100 mg twice a day) was started with rapid improvement of the symptoms.
Thermotherapy with the Alma Accent for the treatment of cutaneous leishmaniasis
(Poster reference number 5355)
Jennifer Ragi, MD, UMDNJ-Robert Wood Johnson Medical School, Somerset, NJ, United States; Amy Pappert, MD, UMDNJ-Robert Wood Johnson Medical School, Somerset, NJ, United States; David Milgraum, Tuoro College, New York, NY, United States; Sandy Milgraum, MD, UMDNJ-Robert Wood Johnson Medical School, Somerset, NJ, United States
Discussion: Syphilis is normally manifested 2 weeks after sexual exposure with the characteristic painless penile ulcer. If left untreated, the infection rapidly progresses to the secondary stage, which is characterized by the appearance of skin rashes that can mimic many other skin diseases. Systemic symptoms such as fever, headache, muscle ache, weight loss, and fatigue may also appear. Although enlargement of inguinal lymph nodes is often detected, penoscrotal elephantiasis is very rare. This manifestation probably appears as a result of the enlargement of the lymph nodes and lymphatic flow obstruction caused by the infection of the genitalia. The incidence of syphilis dramatically declined in the past, probably because of the AIDS prevention campaigns. Unfortunately, nowadays it can be considered as a resurgent disease. Because a misdiagnosis of this infection can have serious consequences for the patient, clinicians should be aware of the many manifestations of syphilis. Conclusion: We present a 54-year-old man with syphilitic elephantiasis of penis and scrotum, which is a very rare manifestation of this disease.
New World leishmaniasis is caused by a protozoan infection of Leishmania species found in Central and South America. It has a wide clinical spectrum ranging from cutaneous ulcers to disfiguring mucocutaneous disease or visceral disease which can be fatal. Treatment for New World cutaneous leishmaniasis (CL) is standard since untreated individuals can develop chronic ulcers, recidivant. lesion or mucocutaneous involvement. Current treatment with intravenous pentavalent antimony is expensive, difficult to obtain, and has numerous adverse effects. While intralesional injection of this medication has less systemic side effects, it is painful and often not preferred by patients. We present a detail case report with clinical images of a patient with Leishmania mexicana who was successfully treated with thermotherapy in an unconventional way. Generally, thermotherapy can be applied with warm water soaks, heating pads, or high-energy light waves. In 2003, the ThermoMed model 1.8 apparatus was approved by the US Food and Drug Administration (FDA) for the treatment of CL by applying radiofrequency heat with a bipolar probe to heat the infected tissue to 508C for 30 seconds. However, this apparatus is not readily available to most dermatologists. In this case report, the infection was successfully treated with the same dose of heat delivered by bipolar radio frequency from the Alma Accent, a cosmetic device. This device is not currently FDA approved for treatment of CL. The authors want to highlight that topical treatment in New World CL is not recommended except in cases of infection with L mexicana where the risk of progression to mucosal leishmaniasis is nearly nonexistent. The mechanism by which thermotherapy successfully cures CL is still unknown. This case report reminds dermatologists that treatment with thermotherapy for CL is efficacious.
Commercial support: None identified.
Commercial support: None identified.
AB114
J AM ACAD DERMATOL
APRIL 2012