Atypical plaquelike staphylococcal folliculitis in human immunodeficiency virus-infected persons

1024 Brief communications

Journal of the American Academy of Dermatology

A common cutaneous problem associated with acquired immunodeficiency syndrome (AIDS) is staphylococcal infections, which occur in more than 50% of patients with AIDS and AIDS-related complex (ARC).l This report describes five cases of an unusual plaquelike staphylococcal folliculitis in human immunodeficiency virus (HIV)-infected persons.

Fig. 4. Appearance of involved area 4 weeks after isotretinoin therapy was instituted. subsequently spread to the trunk.and extremities. Lesions are usually less than 9 rom in size and may be numerous. Mucous membranes, the palms, and the soles can be involved. Scarring occurs with resolution. Our patient's case is similar to the other nine reported cases. Only the forehead was involved in our patient, however, perhaps because of the limited duration of his disease, Perhaps a more generalized eruption would have occurred had isotretinoin therapy not been instituted. REFERENCES 1. Grzybowski M. Case of peculiar generalized epithelial tumors of the skin. Br J Dermatol 1950;62:310-3. 2. WittenVH, Zak FG. Multiple primary, self-healing prickle-cell epithelioma of the skin. Cancer 1952;5:539-50. 3. Rossman RE, Freeman RG, Knox JM. Multiple acanthomas. Arch DermatoI 1964;89:374-81. 4. JollyHW,CarpenterCL, Rouge B. Multiple keratoacanthoma.Arch DermatoI1966;89:374-81. 5. Winkelman RR, Brown J. Generalized eruptive keratoacanthoma. Arch Dermatol 1968;97:615-23. 6. Yoshikawa K, Hirano S, Kato T, et al. A caseof eruptive keratoacanthoma treated byoral etretinate, Br J Dermatol 1985;112:579-83. 7. Young SK, Larsen PE, Markowitz NR. Generalized eruptive keratoacanthoma. Oral Surg Oral Med Oral Pathol 1986;62:422-6.

Atypical plaquelike stapbylococcal folliculitis in

human immunodeficiency virus-infected persons Brad A. Becker, MS,a Ilona J. Frieden, MD,a Richard B. Odom, MD,n and Timothy G. Berger, MDa, b San Francisco. California From the Department of Dermatology, University of California at San Francisco,' and the Department of Dermatology, San Francisco General Hospital. b Reprint requests: Timothy G. Berger, MD, Department of Dermatology, 4M70, San Francisco General Hospital, 1001Potrero Ave., San Francisco, CA 94110.

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Case report (patient 1).ARCwas diagnosed ina 37-year-old white man in June 1987. He was seen in March 1987 with alopecic violaceous plaques studded with pustules inthe axillae andin thesuprapubic area(Fig. 1).Abiopsy ofthesuprapubic plaque was performed. Bacterial cultures grew Staphylococcus aureus that was resistant to penicillin, erythromycin, and clindarnycin. The lesions improved but did not clear with oral dicloxacillin therapy. The patient was then given a 6-month courseofcephradine, 500 mg four times daily, andrifampin, 600 tug] day, with nearly complete clearing. Afterdiscontinuation of treatment, several flares occurred, requiring 6-week courses of cephradine and rifampin, The patient's skin was completely clear after 1 year, and his condition was maintained with topical mupirocin ointment. Theclinical features andtherapeutic results in theotherfour cases are summarized in Table I. Histopathologic findings. All four biopsy specimens showed a similar process at varyingstages of evolution. A dense infiltrate of mononuclearcells surrounded and involvedfollicular structures (Fig. 2). There were focal areas of suppurative folliculitis and a few hair shaft fragments surrounded by histiocytes and giant cellsin the reticular dermis(Fig. 3). Allspecimenscontainedsignificant dermal infiltratesof plasma cellsboth perifollicularly and in the deep dermis. In two cases, periodic acid-Schiff stains werenegative.In the upper reticular dermis, ectatic irregular vascular channels (Fig. 3) were lined by plump, but not atypical, endothelialcells.

Discussion. Cutaneous staphylococcal infections are common in HIV-infected persons.' An early pattern, often present in asymptomatic, seropositive persons, is bullous impetigo of the axillae or groin. Later, facial or truncal folliculitis (superficially resemblingacne), furunculosis, or ecthyma develops. Secondary staphylococcal infection frequently develops in HIV-infected patients with eczematous eruptions. We report another form of staphylococcalinfectionthat occursin HIV-infected persons, usually those with ARC or AIDS. Violaceous plaques up to 10 em in diameter appeared within days to weeks in the groin, axillae, or scalp. In severalcases, dermatologic consultation was sought to exclude Kaposi's sarcoma. Superficial pustules and crusts were common, characteristic features. Cultures were positivefor S. aureus. Therapy directed against this pathogen was effective, but prolongedor repeated courses of oral penicillinase-resistant penicillins or cephalosporins were usually required. The addition of rifampin was useful in accelerating resolution or preventingrelapse. Topical mupirocin ointment led to clearing of lesions in one patient and al-

Volume 21 Number 5, Part 1 November 1989

Brief communications 1025

Fig. 1. Case 1. Violaceous suprapubic plaque. Fig. 2. Case 1. Photomicrograph shows dense perifollicular and dermal perivasular infiltrate. (Hematoxylin-eosin stain; X40.) Fig. 3. Case 2. Photomicrograph of diffusedermal infiltrate with ectatic superficial dermal vessels and free hair shaft fragment in deep dermis. (Hematoxylin-eosin stain; X25.)

Table I. Clinical features and therapeutic results in patients with atypical staphylococcal folliculitis

mv disease status

Therapy

Patient No.

Age (yr)

Risk factors for mv infection

1

37

ARC

AIDS

Axillae, groin

C,R

SP

2

39

Bisexual, IV drug abuse Homosexual

ARC

AIDS

C,R,M

E,K

3 4

34 39 42

Homosexual Homosexual Homosexual

Unknown AIDS AIDS

AIDS AIDS AIDS

Axillae, beard, groin, scalp Beard, scalp, trunk Groin, scalp, trunk Axillae

R,SP SP,TC M

I, K, SP, TC C,K

5

At presentation

I At last visit

Location

Effective

I

Ineffective

C. First-generationcephalosporins; E. erythromycin (systemic); HIV, human immunodeficiency virus; I. imidazoles (topical); K, ketoconazole; M, mupirocin (topical) R. rifampin; SP, semisynthetic penicillins; TC, topicalc1indamycin.

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Journal of the American Academy of Dermatology

Brief communications

loweddiscontinuationoflong-term oral antibiotictherapy in another. Histologic examination showed folliculitis or perifolliculitis or both. The free hair fragments in case 2 and the high content of plasma cellsin all specimens suggestthat chronic follicular inflammation destroyed hair follicles. Prominent superficial vascular ectasia was present, but the dilated channels did not contain erythrocytes; they may have been dilated lymphatic vessels in areas of chronic inflammation. The related vascular ectasia may explain the clinical resemblance to Kaposi's sarcoma. An intact phagocyticsystemisessentialfor normal host defense against S. aureusl' Neutrophil phagocytosis and killing of Candida albicans appear to be normal in homosexual men with AIDS, but the migration and chemotactic response of neutrophils is markedly defective.v" Delayed migration of neutrophils enhances the bacteria's ability to producedisease.5 Thismigrational defect may partly explain why patients with AIDS have an increased number of S. aureus skin infectionsand occasionally have a suboptimal response to treatment. Other explanations for staphylococcal infections in patients with ARC and AIDS may include an increased staphylococcal nasal carriage rate (unpublished data) and a high prevalence of dermatoses (e.g., seborrheic dermatitis) that lead to colonization in the skin. REFERENCES 1. Duvic M, JohnsonTM, Rapini RP, et al. Acquired im-

munodeficiency syndrome: associated psoriasis and Reiter's syndrome. Arch DermatoI1987;123:1622-32. 2. Easmon eSF, Adlam C, eds. Staphylococci and staphylococcal infections; vol l. New York: Academic Press, 1983: 243. 3. Lazzarin A, Foppa CU, Galli M, et al. Impairment ofpolymorphonuclear leucocyte function in patients withacquired immunodeficiency syndrome and with lymphadenopathy syndrome. Clin Exp Immunol 1986;6.5:105-11. 4. Nielsen H, Kharazmi A,FaberV.Blood monocyte andneutrophil functions in the acquired immune deficiency syndrome. Scand J ImmunoI1986;24:291-6. 5. Miles AA, Miles EM, Burke J. The value and duration of defense reactions of the skin to the primary lodgement of bacteria. Br J Exp Pathol 1957;38:79-96.

Is chronic diffuse hepatopathy a manifestation of neurofibromatosis? M. J. Romero, MD, M. Ortega, MD, and F. Camacho, MD Seville, Spain With the aim of studying the existenceof visceral tumors in neurofibromatosis (von Recklinghausen's disFrom the Department ofMedical-Surgical Dermatology and Venereology, Faculty ofMedicine, University ofSeville. Reprint requests: F.Camacho, MD, Departmentof Medical-Surgical Dermatology and Venereology, Faculty ofMedicine, University of Seville, 41009 Seville, Spain. 16/4/11005

ease), weperformedliverscintigraphy in 30 patients.We found diffuse chronic hepatopathy in 13 of 30 patients (43.3%). In 54 patients with melanoma, 11 showed diffuse chronic hepatopathy (20.4%). The difference is statistically significant (p < 0.05). We suspect that diffuse chronic hepatopathy may be a characteristic manifestation of neurofibromatosis. Because we studied only 30 patients, however, this may be a coincidental finding in our country. REFERENCES

1. Yang 8SL, Hsu T-H. Neoplasms of the liver. In: RothIeld B, ed.Nuclearmedicine: hepatolineal, Philadelphia: JB Lippincott, 1980:123-32. 2. Patton DD. Liver scans inspace occupying disease. In:Freeman LM, Weissmann HS, eds, Nuclear medicine annual. New York: Raven Press, 1982:35-79.

Chlorthalidone-induced pseudoporphyria: Clinical and microscopic findings of a case Eric J. Baker, MAJ, MC, USAF,a Kurt D. Reed, MAJ, MC, USAF,b and Steven L. Dixon, MAJ, Me, USA? Lackland Air Force Base, Texas

Pseudoporphyria is a group of bullous photosensitive diseases that mimics porphyriacutanea tarda. Drugs implicated as causative agents include tetracycline,1,2 nalidixic acid,3-5 pyridoxine.f naproxen.v" dapsone,1 and furosemide," One author suggests that pseudoporphyria should be renamed drug- or therapy-induced bullous photosensitivity. 9 The clinical appearance and histologic and ultrastructural findings of pseudoporphyria are strikinglysimilar to porphyria cutanea tarda. Both disorders are characterized by skinfragility,blisters, and miliaafter sunexposure and are often worsened by trauma. Unlike porphyria cutanea tarda, however, hypertrichosis, hyperpigmentation, or sclerodermatous plaques do not develop in patients with pseudoporphyria, and results of porphyrin studies are normal. We presentthe firstreportof pseudoporphyria induced by chlorthalidone (Hygroton). Case report. A 58-year-old white man was seen at Wilford Hall U.S. Air Force Medical Center with a 5-month history of skin fragility and blistering localized to the dorsa ofhis hands. The patient's medical history included atherosclerotic cardiaFrom the Departments ofDermatology" and Pathology,"Wilford Hall U.S. Air Force Medical Center. The opinions expressed herein represent those ofthe authors and do not necessarily represent those ofthe United States Air Force orthe Department of Defense. Reprint requests: Erie J. Baker. MAJ, MC, USAF, Department of Dermatology, Wilford Hall Medical Center, Laekland AFB, TX 78236-5300. 16/4/11001