- Email: [email protected]
Lues maligna
P2307
P2309
Lues maligna Brooke Jeffy, MD, University of Louisville, Department of Medicine, Division of Dermatology, Louisville, KY, United States; Paul Hillesheim, DO, University of Louisville, Department of Pathology and Laboratory Medicine, Louisville, KY, United States; Soon Bahrami, MD, University of Louisville, Department of Medicine, Division of Dermatology, Louisville, KY, United States
New world cutaneous leishmaniasis imported into Spain Husein Husein-ElAhmed, MD, San Cecilio Clinical Hospital, Department of Pathology, Granada, Spain; Francisco O’Valle, MD, PhD, San Cecilio Clinical Hospital, Department of Pathology, Granada, Spain; Jose Aneiros-Fernandez, MD, San Cecilio Clinical Hospital, Department of Pathology, Granada, Spain; Jose Carlos Ruiz Carrascosa, MD, San Cecilio Clinical Hospital, Department of Dermatology, Granada, Spain; Salvador Arias-Santiago, MD, San Cecilio Clinical Hospital, Department of Dermatology, Granada, Spain Background: A case of cutaneous leishmaniasis in a traveller from Venezuela (South America) is reported. Leishmaniasis presents rarely in Spain and delays in diagnosis and treatment often occurs. A high index of suspicion in a patient who has returned from an endemic region is required. Case report: A 12-year-old boy was evaluated for a skin lesion on his left cheek. His parents noticed the lesion 2 days after returning from a 4-week trip to Venezuela. A medical history showed lesion began as a 1-cm diameter raised papule that enlarged over a 2-week period, to the present ulcer. Neither antifungal drugs or antibiotic therapies showed improvement. On examination, we found a well-nourished boy, without fever, with a painless, erythematous, and indurated plaque on left cheek. There were no local or systemic symptoms. No regional lymphadenopathies were noted. Subsequently, a biopsy showed intracellular Leishmania on Giemsa stain and culture yielded promastigotes. Patient received treatment consisting of parenteral injections of meglumine animoniate (20 mg/kg/day) with satisfactory respond after 2 weeks.
Background: Lues maligna is a rare form of secondary syphilis characterized by severe ulcerations, pustules, and constitutional symptoms that has an increased incidence in the immunosuppressed, particularly those with HIV. Patients generally have a very high rapid plasma reagin (RPR) titer and rapid response to treatment with penicillin though a severe JarischeHerxheimer reaction is frequently associated. Observation: A 49-year-old HIV-positive man presented with a 2-month history of painful erythematous rash that started on his back and progressed to involve his face, hands, and feet. Physical examination revealed confluent focally eroded erythema of the face and scalp with thick scale over the cheeks, erosive plaques with scattered vesicles on his back and exfoliative scale of the palms and soles. The patient’s RPR titer was very high (1:32 following 2 dilutions). A punch biopsy specimen obtained from his back showed an interface dermatitis with a superficial and deep perivascular histiocytic infiltrate without the presence of plasma cells; however, Steiner stain and immunohistochemistry confirmed the presence of spirochetes within the epidermis and endothelial cells of the dermal vasculature. He was treated with IV penicillin G and had complete resolution of his skin lesions within 14 days without a JarischeHerxheimer reaction. Conclusion: Although a rare presentation of secondary syphilis, lues maligna should be considered in the differential diagnosis of erosive widespread lesions in all HIVpositive patients.
Conclusion: Differential diagnosis of cutaneous leishmaniasis includes insect bites, traumatic ulcers, fungal and mycobacterial infections, paracocccidioidomycosis and staphylococcal infections. However, a medical history with suspicion in a patient who has returned from an endemic region remains the most useful method for diagnosis.
Commercial support: None identified. Commercial support: None identified.
P2308 ‘‘Racket’’ lesion reaction in a dimorphic tuberculoid leprosy patient Naiana Sa, MD, Universidade Federal de Santa Catarina, Florianopolis, Brazil; Ana Kris Silva, MD, Universidade Federal de Santa Catarina, Florian opolis, Brazil; Evelyne Averbeck, MD, Universidade Federal de Santa Catarina, Florian opolis, Brazil; Marina Guerini, MD, Universidade Federal de Santa Catarina, Florian opolis, Brazil Background: Leprosy (or Hansen disease) is a chronic infectious disease, endemic in Brazil. It is caused by Mycobacterium leprae, acid-fast bacillus with tropism for the peripheral nerves. Its clinical manifestations are characterized by skin lesions and neurologic disorders. The ‘‘racket lesion’’ is presented in the form of a cutaneous nerve branch emerging from a tuberculoid plaque. It is a fairly feature of tuberculoid leprosy and fully demonstration of commitment cutaneous neural this disease. Case report: A 52-year-old man with a 2-year history of nodules and plaques on the body reported with pain, edema, and erythema on the lesions, mainly on the face. At dermatologic examination, he had multiples erythematous plaques on the legs, arms, and trunk. On the face, enlargement of the facial nerve was observed, which emerged from a plaque: a ‘‘racket lesion.’’ Thermal sensitivity was decreased and bacilloscopy was positive. Multidrugtherapy and oral prednisone were initiated. Discussion: Hansen disease is a chronic infectious disease caused by the M leprae. It is considered to be a major public health problem in Brazil. The type of leprosy that affects an individual depends on the immune response mounted against the organism. This leads to a spectrum of disease that can be presented in two welldefined stable and opposite poles (lepromatous and tuberculoid) and two unstable groups (indeterminate and dimorphic). Type 1 reactions are immunologically mediated episodes, localized in skin and nerves, which are a major cause of nerve function impairment. The ‘‘racket lesion’’ is described as cutaneous nerve branch emerging from a tuberculoid plaque. The case reported presented a type 1 reaction, and had a good response with corticoid. Althought the ‘‘racket lesion’’ is described as pathognomonic of tuberculoid leprosy, the clinical examination and bacilloscopy lead to the diagnostic of a dimorphic-tuberculoid form. Early diagnosis and treatment of the leprosy and its reactions can prevent disabilities. Commercial support: None identified.
FEBRUARY 2011
P2310 Atypical secondary syphilis: A case report and review of uncommon presentations of secondary syphilis Peter Mattei, MD, Mcguire AFB, Mcguire AFB, NJ, United States; Chad Hivnor, MD, Wilford Hall Medical Center, Lackland AFB, TX, United States; Michael Murchland, MD, Wilford Hall Medical Center, Lackland AFB, TX, United States; Oliver Wisco, DO, Wilford Hall Medical Center, Lackland AFB, TX, United States; Ryan Johnson, MD, Wilford Hall Medical Center, Lackland Air Force Base, TX, United States Syphilis is a well known sexually transmitted infection that for a time was rarely seen by practitioners in industrialized countries. At present, the rate of infection has been increasing, particularly among HIV infected individuals. Many health care providers have limited clinical experience with this pathogen. With its interesting history and increasing prevalence, syphilis should be prudently recognized by all practitioners today. We present a case of syphilis in a 48-year-old male with one of the many atypical presentations of secondary syphilis and review the literature describing other atypical cases of secondary syphilis. Commercial support: None identified.
J AM ACAD DERMATOL
AB99
P2309
Lues maligna Brooke Jeffy, MD, University of Louisville, Department of Medicine, Division of Dermatology, Louisville, KY, United States; Paul Hillesheim, DO, University of Louisville, Department of Pathology and Laboratory Medicine, Louisville, KY, United States; Soon Bahrami, MD, University of Louisville, Department of Medicine, Division of Dermatology, Louisville, KY, United States
New world cutaneous leishmaniasis imported into Spain Husein Husein-ElAhmed, MD, San Cecilio Clinical Hospital, Department of Pathology, Granada, Spain; Francisco O’Valle, MD, PhD, San Cecilio Clinical Hospital, Department of Pathology, Granada, Spain; Jose Aneiros-Fernandez, MD, San Cecilio Clinical Hospital, Department of Pathology, Granada, Spain; Jose Carlos Ruiz Carrascosa, MD, San Cecilio Clinical Hospital, Department of Dermatology, Granada, Spain; Salvador Arias-Santiago, MD, San Cecilio Clinical Hospital, Department of Dermatology, Granada, Spain Background: A case of cutaneous leishmaniasis in a traveller from Venezuela (South America) is reported. Leishmaniasis presents rarely in Spain and delays in diagnosis and treatment often occurs. A high index of suspicion in a patient who has returned from an endemic region is required. Case report: A 12-year-old boy was evaluated for a skin lesion on his left cheek. His parents noticed the lesion 2 days after returning from a 4-week trip to Venezuela. A medical history showed lesion began as a 1-cm diameter raised papule that enlarged over a 2-week period, to the present ulcer. Neither antifungal drugs or antibiotic therapies showed improvement. On examination, we found a well-nourished boy, without fever, with a painless, erythematous, and indurated plaque on left cheek. There were no local or systemic symptoms. No regional lymphadenopathies were noted. Subsequently, a biopsy showed intracellular Leishmania on Giemsa stain and culture yielded promastigotes. Patient received treatment consisting of parenteral injections of meglumine animoniate (20 mg/kg/day) with satisfactory respond after 2 weeks.
Background: Lues maligna is a rare form of secondary syphilis characterized by severe ulcerations, pustules, and constitutional symptoms that has an increased incidence in the immunosuppressed, particularly those with HIV. Patients generally have a very high rapid plasma reagin (RPR) titer and rapid response to treatment with penicillin though a severe JarischeHerxheimer reaction is frequently associated. Observation: A 49-year-old HIV-positive man presented with a 2-month history of painful erythematous rash that started on his back and progressed to involve his face, hands, and feet. Physical examination revealed confluent focally eroded erythema of the face and scalp with thick scale over the cheeks, erosive plaques with scattered vesicles on his back and exfoliative scale of the palms and soles. The patient’s RPR titer was very high (1:32 following 2 dilutions). A punch biopsy specimen obtained from his back showed an interface dermatitis with a superficial and deep perivascular histiocytic infiltrate without the presence of plasma cells; however, Steiner stain and immunohistochemistry confirmed the presence of spirochetes within the epidermis and endothelial cells of the dermal vasculature. He was treated with IV penicillin G and had complete resolution of his skin lesions within 14 days without a JarischeHerxheimer reaction. Conclusion: Although a rare presentation of secondary syphilis, lues maligna should be considered in the differential diagnosis of erosive widespread lesions in all HIVpositive patients.
Conclusion: Differential diagnosis of cutaneous leishmaniasis includes insect bites, traumatic ulcers, fungal and mycobacterial infections, paracocccidioidomycosis and staphylococcal infections. However, a medical history with suspicion in a patient who has returned from an endemic region remains the most useful method for diagnosis.
Commercial support: None identified. Commercial support: None identified.
P2308 ‘‘Racket’’ lesion reaction in a dimorphic tuberculoid leprosy patient Naiana Sa, MD, Universidade Federal de Santa Catarina, Florianopolis, Brazil; Ana Kris Silva, MD, Universidade Federal de Santa Catarina, Florian opolis, Brazil; Evelyne Averbeck, MD, Universidade Federal de Santa Catarina, Florian opolis, Brazil; Marina Guerini, MD, Universidade Federal de Santa Catarina, Florian opolis, Brazil Background: Leprosy (or Hansen disease) is a chronic infectious disease, endemic in Brazil. It is caused by Mycobacterium leprae, acid-fast bacillus with tropism for the peripheral nerves. Its clinical manifestations are characterized by skin lesions and neurologic disorders. The ‘‘racket lesion’’ is presented in the form of a cutaneous nerve branch emerging from a tuberculoid plaque. It is a fairly feature of tuberculoid leprosy and fully demonstration of commitment cutaneous neural this disease. Case report: A 52-year-old man with a 2-year history of nodules and plaques on the body reported with pain, edema, and erythema on the lesions, mainly on the face. At dermatologic examination, he had multiples erythematous plaques on the legs, arms, and trunk. On the face, enlargement of the facial nerve was observed, which emerged from a plaque: a ‘‘racket lesion.’’ Thermal sensitivity was decreased and bacilloscopy was positive. Multidrugtherapy and oral prednisone were initiated. Discussion: Hansen disease is a chronic infectious disease caused by the M leprae. It is considered to be a major public health problem in Brazil. The type of leprosy that affects an individual depends on the immune response mounted against the organism. This leads to a spectrum of disease that can be presented in two welldefined stable and opposite poles (lepromatous and tuberculoid) and two unstable groups (indeterminate and dimorphic). Type 1 reactions are immunologically mediated episodes, localized in skin and nerves, which are a major cause of nerve function impairment. The ‘‘racket lesion’’ is described as cutaneous nerve branch emerging from a tuberculoid plaque. The case reported presented a type 1 reaction, and had a good response with corticoid. Althought the ‘‘racket lesion’’ is described as pathognomonic of tuberculoid leprosy, the clinical examination and bacilloscopy lead to the diagnostic of a dimorphic-tuberculoid form. Early diagnosis and treatment of the leprosy and its reactions can prevent disabilities. Commercial support: None identified.
FEBRUARY 2011
P2310 Atypical secondary syphilis: A case report and review of uncommon presentations of secondary syphilis Peter Mattei, MD, Mcguire AFB, Mcguire AFB, NJ, United States; Chad Hivnor, MD, Wilford Hall Medical Center, Lackland AFB, TX, United States; Michael Murchland, MD, Wilford Hall Medical Center, Lackland AFB, TX, United States; Oliver Wisco, DO, Wilford Hall Medical Center, Lackland AFB, TX, United States; Ryan Johnson, MD, Wilford Hall Medical Center, Lackland Air Force Base, TX, United States Syphilis is a well known sexually transmitted infection that for a time was rarely seen by practitioners in industrialized countries. At present, the rate of infection has been increasing, particularly among HIV infected individuals. Many health care providers have limited clinical experience with this pathogen. With its interesting history and increasing prevalence, syphilis should be prudently recognized by all practitioners today. We present a case of syphilis in a 48-year-old male with one of the many atypical presentations of secondary syphilis and review the literature describing other atypical cases of secondary syphilis. Commercial support: None identified.
J AM ACAD DERMATOL
AB99