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Dermatitis herpetiformis: An entity probably underdiagnosed
P8465
P8100
Cutaneous Loxoscelism: A diagnosis to consider Lauren Strazzula, Massachusetts General Hospital, Boston, MA, United States; Daniela Kroshinsky, Massachusetts General Hospital, Boston, MA, United States; William Tsiaras, Massachusetts General Hospital, Boston, MA, United States A 17 year-old healthy female presented with a 1-month history of 2 adjacent nonhealing ulcers on her left lower leg, The patient had been awakened from sleep 1 month prior with sharp calf pain while sleeping in a sleeping bag at a friend’s house. She noticed 2 pink papules at that time that subsequently became violaceous, bullous, and then ulcerated. She reported associated myalgias and mild arthralgias. The patient was subsequently seen by her primary care physician and received two courses of sulfamethoxazole/trimethoprim for possible MRSA cellulitis. Because of the persistence of her symptoms, she then presented to the emergency department for dermatologic evaluation. Review of photos taken by her family, her clinical presentation, and the morphology of her lesions were concerning for a Loxosceles spider bite. Basic chemistries and hematology laboratories were within normal limits. A punch biopsy demonstrated an arthropod assault with toxin mediated fat necrosis likely secondary to a Loxosceles spider bite. The toxins from venomous spider bites result in a local cutaneous reaction known as necrotic arachnidism. In the United States, Loxosceles reclusa (brown recluse spider) is the most common spider associated with this phenomenon. The ‘‘red, white, and blue’’ sign describes the initial erythema, subsequent toxin-mediated vasoconstricted pallisading ring, and ultimate bluish necrotic ulcer that is the pathognomic pattern of lesion progression and was documented in this patient. Along with local necrosis, the spider’s toxins can rarely lead to systemic loxoscelism which can present with fever and myalgias and may progress to hemolytic anemia, DIC, and death. The patient in this case was treated with local wound care and seen in the outpatient setting until the ulcers healed. Cutaneous loxoscelism is an important diagnosis to consider, as systemic involvement, while rare, may be fatal.
Delusional infestation presenting with shared delusions: Treatment outcomes from a case series Alia Ahmed, MBBS, Barts Health NHS Trust, London, United Kingdom; Anthony Bewley, MBBS, Barts Health NHS Trust, London, United Kingdom; Reena Shah, PhD, Barts Health NHS Trust, London, United Kingdom; Ruth Taylor, MBBS, Barts Health NHS Trust, London, United Kingdom
Commercial support: None identified.
Background: Delusional infestation (DI) is the persistent belief of pathogenic infestation of the skin or body, without objective medical evidence. Shared delusions can occur between the index case and another individual (folie a deux), and rarely folie a trois may occur. Objectives: The aim of this case review was to investigate treatment outcomes for a series of patients who had DI coexistent with shared delusions (ie, folie a deux/trois). Methods: Three 3 patients who had a diagnosis of DI and shared delusions were identified from a specialist psychodermatology clinic database. Treatment measures and outcomes for the index case and others involved were assessed via medical records and patient letters. Results: All the index cases suffered from DI (2 females, 1 male, age range 35-52 years, mean age 42 years). Two index cases had a diagnosis of DI with folie a trois and 1 case had DI with folie a deux. The patients sharing the delusions were either the spouse of the index case and/or their children. Treatment of 2 of the index cases with an atypical antipsychotic (risperidone) and topical treatment (including antimicrobial emollient therapy) resulted in resolution of the symptoms. Those sharing the delusions were treated topically and experienced symptom resolution without systemic treatment once the index case had been treated. One index case did not comply with risperidone and was treated with a selective serotonin reuptake inhibitor (citalopram); his wife also required the same treatment. Their symptoms, although improved, did not resolve completely. Conclusions: This is the first case series report of treatment outcomes for patients presenting with DI and shared delusions. It is important to ask patients when they present whether their spouse, children, or any other members of their family/friends have similar symptoms. Treatment of the index case with risperidone and topical treatment can result in resolution of symptoms. Those sharing the delusions can be treated topically and symptoms usually resolve without systemic treatment. It is likely once the index case experiences relief from symptoms, those sharing the delusions will follow suit. Commercial support: None identified.
P8654 Dermatitis herpetiformis: An entity probably underdiagnosed Marıa Salazar-Nievas, MD, San Cecilio Hospital, Granada, Spain; Juan M. Rubio-L opez, MD, Jaen City Hospital Complex, Jaen, Spain; Vicente Crespo-Lora, MD, San Cecilio Hospital, Granada, Spain
P8282 Cutaneous RosaieDorfman disease coexisting with nontuberculous mycobacterial infection Shang-Ian Tee, MBBS, National Skin Centre, Singapore, Singapore; Hiok Hee Tan, MBBS, Thomson Specialist Skin Centre, Singapore, Singapore Cutaneous RosaieDorfman disease (RDD) is a rare benign histiocytic proliferative disorder limited to the skin. Its eitiology is unknown, although viral infection was postulated as a possible cause. We report a case of RDD in which nontuberculous mycobacterium (NTM) were found within the lesions on the skin. A 61-year-old Chinese female presented with a 5-month history of a slowly expanding asymptomatic 6- 3 5-cm erythematous plaque on her right upper arm. She was otherwise in good health and did not recall preceding trauma. The regional lymph nodes were not palpable. Skin biopsy revealed a diffuse and nodular infiltrate of histiocytes exhibiting emperipolesis of lymphocytes and plasma cells. Stains for CD68 and S100 protein were positive within the histiocytes. Interestingly, acid fast bacilli were also seen on ZiehleNeelsen stain and polymerase chain reaction confirmed the presence of NTM DNA. She was treated with a combination of oral ciprofloxacin 500 mg bd and clarithromycin 500 mg bd for 7 months, with clinical improvement in the size and thickness of the lesion. To our knowledge, the association of NTM with RDD has not been reported before. The clinical improvement encountered with antibiotic treatment for NTM appears to support an infective eitiology for RDD in our patient, and should be considered in the work-up of cases in future. Commercial support: None identified.
MAY 2014
Overview: Dermatitis herpetiformis (DH) is a subepidermal bullous disease characterized by chronic recurrence of itchy, erythematous papules, urticarial wheals and grouped vesicles that appear symmetrically on the extensor surfaces, buttocks and back. Case report: A 46-year-old man born in Senegal was worried about the episodic appearance of erythematous and vesicular lesions on the trunk, legs, and arms since last 4 years. The patient did not show relevant medical history or other symptoms and denied drug intake. The examinations shown he presented small papular and vesicular lesions which were grouped in small plaques. The differential diagnosis of eczema, impetigo, prurigo and bullous pemphigoid was established. A punch biopsy was done with a sample taken from a lesion located in the right forearm. In the hematoxylineeosin staining is shown findings compatible with dermatitis herpetiformis. The patient was treated with oral dapsona at doses of 50 mg/day and glutenfree diet with improvement. Comment: Dermatitis herpetiformis is often underdiagnosed. It is important suspected this disease in patients with vesicular and papular lesions in areas of extension, very itchy, and no improvement with corticosteroid treatment. Actually, because of immigration it is necessary that the dermatologists are trained to diagnose dermatoses in all skin types, especially skin color where physical examination can be more difficult. A correct and early diagnosis of dermatitis herpetiformis is essential as this disease is the cutaneous expression of a glutensensitive enteropathy identifiable with celiac disease. Commercial support: None identified.
J AM ACAD DERMATOL
AB41
P8100
Cutaneous Loxoscelism: A diagnosis to consider Lauren Strazzula, Massachusetts General Hospital, Boston, MA, United States; Daniela Kroshinsky, Massachusetts General Hospital, Boston, MA, United States; William Tsiaras, Massachusetts General Hospital, Boston, MA, United States A 17 year-old healthy female presented with a 1-month history of 2 adjacent nonhealing ulcers on her left lower leg, The patient had been awakened from sleep 1 month prior with sharp calf pain while sleeping in a sleeping bag at a friend’s house. She noticed 2 pink papules at that time that subsequently became violaceous, bullous, and then ulcerated. She reported associated myalgias and mild arthralgias. The patient was subsequently seen by her primary care physician and received two courses of sulfamethoxazole/trimethoprim for possible MRSA cellulitis. Because of the persistence of her symptoms, she then presented to the emergency department for dermatologic evaluation. Review of photos taken by her family, her clinical presentation, and the morphology of her lesions were concerning for a Loxosceles spider bite. Basic chemistries and hematology laboratories were within normal limits. A punch biopsy demonstrated an arthropod assault with toxin mediated fat necrosis likely secondary to a Loxosceles spider bite. The toxins from venomous spider bites result in a local cutaneous reaction known as necrotic arachnidism. In the United States, Loxosceles reclusa (brown recluse spider) is the most common spider associated with this phenomenon. The ‘‘red, white, and blue’’ sign describes the initial erythema, subsequent toxin-mediated vasoconstricted pallisading ring, and ultimate bluish necrotic ulcer that is the pathognomic pattern of lesion progression and was documented in this patient. Along with local necrosis, the spider’s toxins can rarely lead to systemic loxoscelism which can present with fever and myalgias and may progress to hemolytic anemia, DIC, and death. The patient in this case was treated with local wound care and seen in the outpatient setting until the ulcers healed. Cutaneous loxoscelism is an important diagnosis to consider, as systemic involvement, while rare, may be fatal.
Delusional infestation presenting with shared delusions: Treatment outcomes from a case series Alia Ahmed, MBBS, Barts Health NHS Trust, London, United Kingdom; Anthony Bewley, MBBS, Barts Health NHS Trust, London, United Kingdom; Reena Shah, PhD, Barts Health NHS Trust, London, United Kingdom; Ruth Taylor, MBBS, Barts Health NHS Trust, London, United Kingdom
Commercial support: None identified.
Background: Delusional infestation (DI) is the persistent belief of pathogenic infestation of the skin or body, without objective medical evidence. Shared delusions can occur between the index case and another individual (folie a deux), and rarely folie a trois may occur. Objectives: The aim of this case review was to investigate treatment outcomes for a series of patients who had DI coexistent with shared delusions (ie, folie a deux/trois). Methods: Three 3 patients who had a diagnosis of DI and shared delusions were identified from a specialist psychodermatology clinic database. Treatment measures and outcomes for the index case and others involved were assessed via medical records and patient letters. Results: All the index cases suffered from DI (2 females, 1 male, age range 35-52 years, mean age 42 years). Two index cases had a diagnosis of DI with folie a trois and 1 case had DI with folie a deux. The patients sharing the delusions were either the spouse of the index case and/or their children. Treatment of 2 of the index cases with an atypical antipsychotic (risperidone) and topical treatment (including antimicrobial emollient therapy) resulted in resolution of the symptoms. Those sharing the delusions were treated topically and experienced symptom resolution without systemic treatment once the index case had been treated. One index case did not comply with risperidone and was treated with a selective serotonin reuptake inhibitor (citalopram); his wife also required the same treatment. Their symptoms, although improved, did not resolve completely. Conclusions: This is the first case series report of treatment outcomes for patients presenting with DI and shared delusions. It is important to ask patients when they present whether their spouse, children, or any other members of their family/friends have similar symptoms. Treatment of the index case with risperidone and topical treatment can result in resolution of symptoms. Those sharing the delusions can be treated topically and symptoms usually resolve without systemic treatment. It is likely once the index case experiences relief from symptoms, those sharing the delusions will follow suit. Commercial support: None identified.
P8654 Dermatitis herpetiformis: An entity probably underdiagnosed Marıa Salazar-Nievas, MD, San Cecilio Hospital, Granada, Spain; Juan M. Rubio-L opez, MD, Jaen City Hospital Complex, Jaen, Spain; Vicente Crespo-Lora, MD, San Cecilio Hospital, Granada, Spain
P8282 Cutaneous RosaieDorfman disease coexisting with nontuberculous mycobacterial infection Shang-Ian Tee, MBBS, National Skin Centre, Singapore, Singapore; Hiok Hee Tan, MBBS, Thomson Specialist Skin Centre, Singapore, Singapore Cutaneous RosaieDorfman disease (RDD) is a rare benign histiocytic proliferative disorder limited to the skin. Its eitiology is unknown, although viral infection was postulated as a possible cause. We report a case of RDD in which nontuberculous mycobacterium (NTM) were found within the lesions on the skin. A 61-year-old Chinese female presented with a 5-month history of a slowly expanding asymptomatic 6- 3 5-cm erythematous plaque on her right upper arm. She was otherwise in good health and did not recall preceding trauma. The regional lymph nodes were not palpable. Skin biopsy revealed a diffuse and nodular infiltrate of histiocytes exhibiting emperipolesis of lymphocytes and plasma cells. Stains for CD68 and S100 protein were positive within the histiocytes. Interestingly, acid fast bacilli were also seen on ZiehleNeelsen stain and polymerase chain reaction confirmed the presence of NTM DNA. She was treated with a combination of oral ciprofloxacin 500 mg bd and clarithromycin 500 mg bd for 7 months, with clinical improvement in the size and thickness of the lesion. To our knowledge, the association of NTM with RDD has not been reported before. The clinical improvement encountered with antibiotic treatment for NTM appears to support an infective eitiology for RDD in our patient, and should be considered in the work-up of cases in future. Commercial support: None identified.
MAY 2014
Overview: Dermatitis herpetiformis (DH) is a subepidermal bullous disease characterized by chronic recurrence of itchy, erythematous papules, urticarial wheals and grouped vesicles that appear symmetrically on the extensor surfaces, buttocks and back. Case report: A 46-year-old man born in Senegal was worried about the episodic appearance of erythematous and vesicular lesions on the trunk, legs, and arms since last 4 years. The patient did not show relevant medical history or other symptoms and denied drug intake. The examinations shown he presented small papular and vesicular lesions which were grouped in small plaques. The differential diagnosis of eczema, impetigo, prurigo and bullous pemphigoid was established. A punch biopsy was done with a sample taken from a lesion located in the right forearm. In the hematoxylineeosin staining is shown findings compatible with dermatitis herpetiformis. The patient was treated with oral dapsona at doses of 50 mg/day and glutenfree diet with improvement. Comment: Dermatitis herpetiformis is often underdiagnosed. It is important suspected this disease in patients with vesicular and papular lesions in areas of extension, very itchy, and no improvement with corticosteroid treatment. Actually, because of immigration it is necessary that the dermatologists are trained to diagnose dermatoses in all skin types, especially skin color where physical examination can be more difficult. A correct and early diagnosis of dermatitis herpetiformis is essential as this disease is the cutaneous expression of a glutensensitive enteropathy identifiable with celiac disease. Commercial support: None identified.
J AM ACAD DERMATOL
AB41