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A case of New World cutaneous leishmaniasis in Danville, PA
INFECTION—BACTERIAL AND PARASITIC 3522 A case of New World cutaneous leishmaniasis in Danville, PA Jill Henley, DO, Geisinger Medical Center, Danville, PA, United States; Christen Mowad, MD, Geisinger Medical Center, Danville, PA, United States; William Tyler, MD, Geisinger Medical Center, Danville, PA, United States Background: New World cutaneous leishmaniasis is a protozoal infectious disease transmitted by a bite from the Lutzomyia sandfly that is not commonly seen in the U.S. outside of South-Central Texas. It is most commonly seen in those who have traveled to endemic areas such as Central or South America, and is most commonly caused by the subspecies Leishmania mexicana or L braziliensis. Case report: A 21-year-old woman presented to the clinic with a 5-month history of a slowly progressive, nonhealing erythematous 2-cm crusted plaque on the left cheek that had initially appeared as a ‘‘pimple-like bump’’ while studying abroad in Costa Rica. The lesion had been previously biopsied by an outside physician, but pathology showed nonspecific inflammation and she was subsequently treated with topical antibiotics. She had developed no other mucocutaneous findings or systemic symptoms despite enlargement of the lesion and thickened crust formation. Her previous slides from the left cheek were requested and read within the Geisinger system, revealing multiple amastigotes in small clusters within the papillary dermis and within the cytoplasm of the dermal histiocytes. An additional biopsy was sent to the CDC for PCR and DNA sequencing and came back positive for the subspecies L panamensis. After consulting with the CDC, she was started on oral ketoconazole 600 mg daily for 30 days. She responded well to the treatment with resolution of the lesion and residual scar formation. Discussion: Cutaneous leishmaniasis due to L panamensis, a subgroup of the species L braziliensis, is a common cause of New World protozoal infections endemic to Central and South America. Infections begin as a papule at the site of inoculation from the bite of a sandfly that slowly grows into an ulcerated plaque or nodule, leading to scar. Histopathology commonly shows amastigotes within dermal macrophages with a mixed inflammatory infiltrate. Lesions can be cultured using specialized Nicolle-Novy-MacNeal media available from the CDC. Cultures are positive in approximately 40% of cases. PCR is the most sensitive and specific diagnostic test. Real-time PCR assay is available at the CDC. Ketoconazole at a dose of 600 mg/day for 28 days has been shown to be more effective than sodium stibogluconate in small studies. Side effects include transient aminitis and reversible decrease in serum testosterone. Conclusion: New World cutaneous leishmaniasis may go unrecognized without high clinical suspicion and history of travel to endemic areas. Diagnosis can be confirmed by pathology, culture, and real-time PCR.
3301 An unusual presentation of primary cutaneous nocardiosis Emily Ward-Shelley, DO, UH Richmond Medical Center, Richmond Heights, OH, United States; Annette Dinneen, MD, Dermatology Associates of Indiana, Indianapolis, IN, United States Introduction: Nocardiosis is an uncommon cause of infection seen in 500-1000 people annually in the United States. The primary cutaneous form of the disease is the least common and is seen in just 5-7% of these cases. Direct inoculation of the immunocompromised host by means of trauma or surgery is the usual route of infection. However, we present a case of infection without history of skin barrier compromise. Case Presentation: A 71-year-old man with a history of non-Hodgkin lymphoma presented with a one-week history of a painful abscess on the right hip. He was otherwise well with no systemic symptoms or fever. He denied any local trauma to the area, but did note he had placed a food wrapper in his waistband around the area that was subsequently affected. The lesion was cultured and grew Nocardia. Treatment with trimethoprim-sulfamethoxazole was initiated and within one week the lesions showed much improvement. Discussion: To our knowledge, this is the first case of primary cutaneous nocardiosis to cause infection of the skin without preceding trauma. We hypothesize that infection may have been caused by contact with a contaminated material. Although primary cutaneous infection caused by Nocardia is uncommon, it should be suspected for soft tissue infections occurring in the immunocompromised host. Commercial support: None identified.
Commercial support: None identified.
2682
3740
Atypical cutaneous mycobacteriosis by M mucogenicum mimicking squamous cell carcinoma in immunocompetent patient Ricardo Ruiz-Villaverde, MD, PhD, Hospital Virgen de las Nieves, Granada, Spain; Pablo Fernandez-Crehuet, MD, PhD, Hospital Alto Guadalquivir, Jaen (Andujar), Spain; Antonio Martinez-Lopez, MD, Hospital Virgen de las Nieves, Granada, Spain; Jose Aneiros-Fernandez, MD, Hospital Virgen de las Nieves, Granada, Spain
A protean master mimic: Secondary syphilis presenting as psoriasiform balanitis Raheel Zubair, MS, MHS, Georgetown University School of Medicine, Washington, DC, United States; Wen Chen, MD, MS, Washington DC VA Medical Center, Washington, DC, United States; Pooja Khera, MD, Washington DC VA Medical Center, Washington, DC, United States Case Description: The patient is a 47-year-old white male who presented to our facility complaining of a 1-month history of a pruritic erythematous, scaly, psoriasiform rash of the penis. He was referred to dermatology by his primary care provider (PCP) after self-treatment with over-the-counter (OTC) clomitrazole and emollients had failed to improve his symptoms. A few weeks prior, the patient had an episode of penile discharge, tested negative for gonorrhea and chlamydia, was treated with azithromycin, and had complete resolution of symptoms. He was found to have reactive RPR and FTA-ABS titers. Punch biopsy revealed T pallidum on WarthinStarry and immunohistochemical staining. Based on this information he was given a diagnosis of secondary syphilis. A sexual history revealed that the patient had unprotected intercourse with a known male partner who tested positive for syphilis. He was successfully treated with 3 doses of IM penicillin G with improvement of his rash and pruritus and no complications. Discussion: This patient’s case illustrates the importance of recognizing the diverse presentations of syphilis and the threat it poses to vulnerable populations. Syphilis is known as ‘‘the great imitator’’ due to its myriad diverse manifestations that can be difficult to distinguish from other diseases. The erythematous scaly psoriasiform patches on this patient represent a rare and unusual presentation of secondary syphilis, which, although very polymorphic, is much more often macular or maculopapular. Syphilis has shown a rising incidence in the United States and men who have sex with men (MSM) are at higher risk than other populations. Diagnosing and treating syphilis is vital, because if unrecognized it can lead to highly destructive and often irreversible cardiac and neurologic effects. Improved provider awareness as well as patient education and safe practices may combat this trend and prevent these unfortunate sequelae.
Introduction: Different mycobacterial species from Mycobacterium tuberculosis and Mycobacterium leprae have been called as environmental, opportunistic or atypical mycobacteria, although the term of nontuberculous mycobacteria (NTM) is one of the most accepted today. We report an interesting clinical case of a cutaneous infection produced by M mucogenicum mimicking a squamous cell carcinoma in an immunocompetent patient. Case report: A 59-year-old male was attended in our dermatology unit complaining about an excrescent cutaneous tumor of rapid growth, which had developed for the previous three months. He denied contact with animals, though regarding his occupation, he admitted an occasional prick with a rose thorn. On clinical examination, an infiltrated erythematous tumor with markedly hyperkeratosis in the central part could be appreciated on the dorsal aspect of his right hand. No locoregional lymph nodes and hepatosplenomegaly were observed. Histologic examination showed the existence of pseudoepitheliomatous hyperplasia with presence of acute inflammatory reaction. Ziehl Nielsen, Fite Faraco and periodic acideSchiff (PAS) stains, as well as the smear, were all negative. However, the culture showed the presence of nonpigmented mucoid colonies of alcohol-resistant bacilli (AFB). Species identification based on 16S rRNA was consistent with M mucogenicum. The patient was started on clarithromycin 500 mg twice daily, in association to rifampicin 300 mg, twice daily, with resolution of symptoms at 3 months. Discussion: M mucogenicum is a fast-growing NTM, formerly known as M chelonaelike. Infections due to M mucogenicum are extremely rare, but often involve skin and soft tissues. Immunocompetent patients rarely develop severe infections. It can also induce a granulomatous hepatitis, pneumonia in AIDS patients and skin infections in patients treated with TNF blockers. From a clinical point of view, the presentation of cutaneous infections caused by NTM may be highly variable. Differential diagnosis includes common warts, verrucous tuberculosis, acquarium granuloma, sporotrichosis, and squamous cell carcinoma, as in the present case. DNA sequencing may be used to identify the exact subtype isolated from culture. There is no defined therapeutic regimen for its treatment due to the existence of multiple bacterial resistances. A combination of two or more agents should be considered in immunocompromised patients.
Commercial support: None identified.
Commercial support: None identified.
MAY 2016
J AM ACAD DERMATOL
AB149
3301 An unusual presentation of primary cutaneous nocardiosis Emily Ward-Shelley, DO, UH Richmond Medical Center, Richmond Heights, OH, United States; Annette Dinneen, MD, Dermatology Associates of Indiana, Indianapolis, IN, United States Introduction: Nocardiosis is an uncommon cause of infection seen in 500-1000 people annually in the United States. The primary cutaneous form of the disease is the least common and is seen in just 5-7% of these cases. Direct inoculation of the immunocompromised host by means of trauma or surgery is the usual route of infection. However, we present a case of infection without history of skin barrier compromise. Case Presentation: A 71-year-old man with a history of non-Hodgkin lymphoma presented with a one-week history of a painful abscess on the right hip. He was otherwise well with no systemic symptoms or fever. He denied any local trauma to the area, but did note he had placed a food wrapper in his waistband around the area that was subsequently affected. The lesion was cultured and grew Nocardia. Treatment with trimethoprim-sulfamethoxazole was initiated and within one week the lesions showed much improvement. Discussion: To our knowledge, this is the first case of primary cutaneous nocardiosis to cause infection of the skin without preceding trauma. We hypothesize that infection may have been caused by contact with a contaminated material. Although primary cutaneous infection caused by Nocardia is uncommon, it should be suspected for soft tissue infections occurring in the immunocompromised host. Commercial support: None identified.
Commercial support: None identified.
2682
3740
Atypical cutaneous mycobacteriosis by M mucogenicum mimicking squamous cell carcinoma in immunocompetent patient Ricardo Ruiz-Villaverde, MD, PhD, Hospital Virgen de las Nieves, Granada, Spain; Pablo Fernandez-Crehuet, MD, PhD, Hospital Alto Guadalquivir, Jaen (Andujar), Spain; Antonio Martinez-Lopez, MD, Hospital Virgen de las Nieves, Granada, Spain; Jose Aneiros-Fernandez, MD, Hospital Virgen de las Nieves, Granada, Spain
A protean master mimic: Secondary syphilis presenting as psoriasiform balanitis Raheel Zubair, MS, MHS, Georgetown University School of Medicine, Washington, DC, United States; Wen Chen, MD, MS, Washington DC VA Medical Center, Washington, DC, United States; Pooja Khera, MD, Washington DC VA Medical Center, Washington, DC, United States Case Description: The patient is a 47-year-old white male who presented to our facility complaining of a 1-month history of a pruritic erythematous, scaly, psoriasiform rash of the penis. He was referred to dermatology by his primary care provider (PCP) after self-treatment with over-the-counter (OTC) clomitrazole and emollients had failed to improve his symptoms. A few weeks prior, the patient had an episode of penile discharge, tested negative for gonorrhea and chlamydia, was treated with azithromycin, and had complete resolution of symptoms. He was found to have reactive RPR and FTA-ABS titers. Punch biopsy revealed T pallidum on WarthinStarry and immunohistochemical staining. Based on this information he was given a diagnosis of secondary syphilis. A sexual history revealed that the patient had unprotected intercourse with a known male partner who tested positive for syphilis. He was successfully treated with 3 doses of IM penicillin G with improvement of his rash and pruritus and no complications. Discussion: This patient’s case illustrates the importance of recognizing the diverse presentations of syphilis and the threat it poses to vulnerable populations. Syphilis is known as ‘‘the great imitator’’ due to its myriad diverse manifestations that can be difficult to distinguish from other diseases. The erythematous scaly psoriasiform patches on this patient represent a rare and unusual presentation of secondary syphilis, which, although very polymorphic, is much more often macular or maculopapular. Syphilis has shown a rising incidence in the United States and men who have sex with men (MSM) are at higher risk than other populations. Diagnosing and treating syphilis is vital, because if unrecognized it can lead to highly destructive and often irreversible cardiac and neurologic effects. Improved provider awareness as well as patient education and safe practices may combat this trend and prevent these unfortunate sequelae.
Introduction: Different mycobacterial species from Mycobacterium tuberculosis and Mycobacterium leprae have been called as environmental, opportunistic or atypical mycobacteria, although the term of nontuberculous mycobacteria (NTM) is one of the most accepted today. We report an interesting clinical case of a cutaneous infection produced by M mucogenicum mimicking a squamous cell carcinoma in an immunocompetent patient. Case report: A 59-year-old male was attended in our dermatology unit complaining about an excrescent cutaneous tumor of rapid growth, which had developed for the previous three months. He denied contact with animals, though regarding his occupation, he admitted an occasional prick with a rose thorn. On clinical examination, an infiltrated erythematous tumor with markedly hyperkeratosis in the central part could be appreciated on the dorsal aspect of his right hand. No locoregional lymph nodes and hepatosplenomegaly were observed. Histologic examination showed the existence of pseudoepitheliomatous hyperplasia with presence of acute inflammatory reaction. Ziehl Nielsen, Fite Faraco and periodic acideSchiff (PAS) stains, as well as the smear, were all negative. However, the culture showed the presence of nonpigmented mucoid colonies of alcohol-resistant bacilli (AFB). Species identification based on 16S rRNA was consistent with M mucogenicum. The patient was started on clarithromycin 500 mg twice daily, in association to rifampicin 300 mg, twice daily, with resolution of symptoms at 3 months. Discussion: M mucogenicum is a fast-growing NTM, formerly known as M chelonaelike. Infections due to M mucogenicum are extremely rare, but often involve skin and soft tissues. Immunocompetent patients rarely develop severe infections. It can also induce a granulomatous hepatitis, pneumonia in AIDS patients and skin infections in patients treated with TNF blockers. From a clinical point of view, the presentation of cutaneous infections caused by NTM may be highly variable. Differential diagnosis includes common warts, verrucous tuberculosis, acquarium granuloma, sporotrichosis, and squamous cell carcinoma, as in the present case. DNA sequencing may be used to identify the exact subtype isolated from culture. There is no defined therapeutic regimen for its treatment due to the existence of multiple bacterial resistances. A combination of two or more agents should be considered in immunocompromised patients.
Commercial support: None identified.
Commercial support: None identified.
MAY 2016
J AM ACAD DERMATOL
AB149