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Oral manifestations of syphilis: Clinical characteristics, differential diagnosis and serologic profile of patients with syphilis in the oral cavity
1640
630
Nasal bridge Nocardia via direct inoculation in a nonimmunosuppressed patient Marina Shuster, Brigham and Women’s Hospital Brigham Dermatology Associates, Boston, MA, United States; Vaneeta Sheth, MD, Brigham and Women’s Hospital Brigham Dermatology Associates, Boston, MA, United States
Old World meets New World leishmaniasis: Leishmania tropica in South Florida Ann Mazor-Reed, DO, NSU-COM/Larkin Community Hospital, Miami, FL, United States
A 42-year-old nurse presented with a 3-day history of a progressively worsening red, swollen, and painful plaque on her nose. Ten days prior to presentation, she fell off her bicycle into a patch of dirt, resulting in an abrasion over her nasal bridge that reportedly healed. At initial presentation, physical examination was notable for an erythematous subcutaneous inflamed nodule draining purulent material from an open punctum with an additional pustule overlying the nasal bridge. A culture was taken and patient was started on twice daily doxycycline and mupirocin ointment. Cultures grew 4+ suspected skin flora. She represented two days later with increased pain and swelling of her nose, worsening headaches and cervical lymphadenopathy. Physical examination was notable for several grouped weeping pustules over the nasal bridge on a background of tender erythematous edema with minimal fluctuance consistent with soft tissue swelling. Repeat culture was taken and the patient was switched to twice daily trimethoprim-sulfamethoxazole with mupirocin. Repeat culture grew Nocardia braziliensis. Nocardia typically presents in the setting of defects in cell-mediated immunity. However, this was not the case in our patient. HIV testing was negative was well. The patient has improved with antimicrobial therapy, and she continues to be followed one month later by infectious disease in order to establish an appropriate end point to trimethoprimsulfamethoxazole therapy. This represents a unique case of Nocardia of the nasal bridge via seemingly direct inoculation in a nonimmunosuppressed patient.
Leishmania tropica is typically found in the Middle East, however, we present a case of Leishmania tropica diagnosed in South Florida. Leishmaniasis is becoming more prevalent in the United States due to the increase in rural travel and the return of military personnel from the Middle East. This disease should be included in the dermatologist’s differential diagnosis when encountering a patient with pertinent occupational or travel history and treat with methods that are convenient and easily accessible. The traditional treatment uses pentavalent antimony, however, oral fluconazole was found to be successful in the treatment of this patient with Leishmania tropica. Commercial support: None identified.
Commercial support: None identified.
1977 Nodules overlying the metacarpal and interphalangeal joints as a cutaneous manifestation in AIDS-related visceral leishmaniasis Lara Angulo Martınez, MD, Hospital 12 Universitario 12 de Octubre, Madrid, Spain; Vanessa Gargallo Moneva, MD, Hospital 12 Universitario 12 de Octubre, Madrid, Spain; Fatima Tous Romero, MD, Hospital 12 Universitario 12 de Octubre, Madrid, Spain; Carlota Gutierrez Garcıa- Rodrigo, MD, Hospital 12 Universitario 12 de Octubre, Madrid, Spain; Carlos Zarco Olivo, MD, Hospital 12 Universitario 12 de Octubre, Madrid, Spain; Francisco Vanaclocha Sebastian, MD, Hospital 12 Universitario 12 de Octubre, Madrid, Spain
Oral manifestations of syphilis: Clinical characteristics, differential diagnosis and serologic profile of patients with syphilis in the oral cavity Dimitrios Tsaknakis, MD, Department of Dermatology, University of Athens School of Medicine, A. Syggros Hospital, Athens, Greece; Electra Nicolaidou, MD, Department of Dermatology, University of Athens School of Medicine, A. Syggros Hospital, Athens, Greece; Christina Antoniou, MD, Department of Dermatology, University of Athens School of Medicine, A. Syggros Hospital, Athens, Greece; Sevasti Afantenou, MD, Department of Dermatology, University of Athens School of Medicine, A. Syggros Hospital, Athens, Greece; Eleni Gagari, DMD, Department of Dermatology, University of Athens School of Medicine, A. Syggros Hospital, Athens, Greece
Visceral leishmaniasis (VL) is an endemic parasitosis in India, East Africa, South America, the Mediterranean area, Central Asia and China. This infection is more prevalent in subjects with human immunodeficiency virus infection (HIV). The burden of HIV/leishmania coinfection is increasing in many developing countries; however, the effective antiretroviral therapy has led to a marked decrease in its incidence in Europe. A 40-year-old woman intravenous drug user and HIV positive was hospitalized in November of 2013 for a clinical picture characterized by fever, diarrhea and wasting. The cutaneous examination disclosed well-marginated nodules with firm consistence overlying the metacarpal and interphalangeal joints and following the path of the palmar aponeurosis. She had a previous history of VL diagnosed in 2011. The laboratory test showed pancytopenia and urine positive antigenuria for leishmaniasis. A biopsy of the nodules was performed where a dense infiltrate of macrophages in the dermis was observed with several amastigotes on hematoxylineeosin staining and on Giemsa staining. She was diagnosed with VL. She was treated with liposomal amphotericin B, suffering an allergic reaction. The treatment was changed to miltefosine, achieving a quick improvement with a complete clearance of the cutaneous lesions. The clinical features of VL in HIVpositive patients are often not classical and the cutaneous lesions attributed to leishmania are very seldom observed. The most frequent skin lesions in VL are macules, papules, plaques, nodules, and ulcers. Psoriasiform and dermatomyositislike eruptions have also been described. Nodule lesions have been extensively reported, however only 3 cases similar to ours have been described in the literature. In these cases, the nodules on the joints can be observed. Our case showed also nodules following the path of the palmar aponeurosis. This location has not been reported yet in the literature.
Syphilis is a sexually transmitted disease (STD) caused by Treponema pallidum that presents in primary, secondary and tertiary stages. Diagnosis of syphilis is often difficult as it may resemble a host of other disease entities and requires increased level of suspicion from the clinician as well as familiarization with the clinical manifestations of the disease. In particular, oral manifestations of syphilis may be very hard to diagnose. We present a case series of 12 patients diagnosed with secondary syphilis primarily from oral cavity lesions at the Oral Medicine Clinic of A. Syggros Hospital for Dermatologic and Venereal Diseases (1st University Clinic of Dermatology). Oral lesions were characterized by redness, erosions, lichenoid mucositis-like white patches, ulcers, and exophytic lesions, present for at least three weeks. The most common sites affected were palate and tongue, although all parts of the oral cavity may be affected. The majority of the patients had no skin lesions at the time of diagnosis which was rendered by serologic testing for VDRL, EIAIgG, EIAIgM and TPPA, after clinical evaluation of the oral cavity lesions raised the possibility of syphilis. Biopsy was performed in three cases, by the patient’s referring physician as a means to elucidate differential diagnosis prior to referral to our center. Histology in these cases demonstrated nonpathognomonic psoriasiform mucositis. Darkfield microscopy of the oral lesions is not recommended and was not performed, as oral microbial flora may produce a false positive result. Oral lesions resolved 2-3 weeks after administration of the appropriate treatment (penicillin G benzathine 2.4 million units IM) by the STD Clinic in our hospital. In summary, oral manifestations of syphilis are an important and difficult to diagnose aspect of a sexually transmitted disease that is on the rise. We present a comprehensive series of oral lesions of secondary syphilis so the dermatologist may be familiar with their characteristics.
Commercial support: None identified.
Commercial support: None identified.
1214
AB128
J AM ACAD DERMATOL
MAY 2015
630
Nasal bridge Nocardia via direct inoculation in a nonimmunosuppressed patient Marina Shuster, Brigham and Women’s Hospital Brigham Dermatology Associates, Boston, MA, United States; Vaneeta Sheth, MD, Brigham and Women’s Hospital Brigham Dermatology Associates, Boston, MA, United States
Old World meets New World leishmaniasis: Leishmania tropica in South Florida Ann Mazor-Reed, DO, NSU-COM/Larkin Community Hospital, Miami, FL, United States
A 42-year-old nurse presented with a 3-day history of a progressively worsening red, swollen, and painful plaque on her nose. Ten days prior to presentation, she fell off her bicycle into a patch of dirt, resulting in an abrasion over her nasal bridge that reportedly healed. At initial presentation, physical examination was notable for an erythematous subcutaneous inflamed nodule draining purulent material from an open punctum with an additional pustule overlying the nasal bridge. A culture was taken and patient was started on twice daily doxycycline and mupirocin ointment. Cultures grew 4+ suspected skin flora. She represented two days later with increased pain and swelling of her nose, worsening headaches and cervical lymphadenopathy. Physical examination was notable for several grouped weeping pustules over the nasal bridge on a background of tender erythematous edema with minimal fluctuance consistent with soft tissue swelling. Repeat culture was taken and the patient was switched to twice daily trimethoprim-sulfamethoxazole with mupirocin. Repeat culture grew Nocardia braziliensis. Nocardia typically presents in the setting of defects in cell-mediated immunity. However, this was not the case in our patient. HIV testing was negative was well. The patient has improved with antimicrobial therapy, and she continues to be followed one month later by infectious disease in order to establish an appropriate end point to trimethoprimsulfamethoxazole therapy. This represents a unique case of Nocardia of the nasal bridge via seemingly direct inoculation in a nonimmunosuppressed patient.
Leishmania tropica is typically found in the Middle East, however, we present a case of Leishmania tropica diagnosed in South Florida. Leishmaniasis is becoming more prevalent in the United States due to the increase in rural travel and the return of military personnel from the Middle East. This disease should be included in the dermatologist’s differential diagnosis when encountering a patient with pertinent occupational or travel history and treat with methods that are convenient and easily accessible. The traditional treatment uses pentavalent antimony, however, oral fluconazole was found to be successful in the treatment of this patient with Leishmania tropica. Commercial support: None identified.
Commercial support: None identified.
1977 Nodules overlying the metacarpal and interphalangeal joints as a cutaneous manifestation in AIDS-related visceral leishmaniasis Lara Angulo Martınez, MD, Hospital 12 Universitario 12 de Octubre, Madrid, Spain; Vanessa Gargallo Moneva, MD, Hospital 12 Universitario 12 de Octubre, Madrid, Spain; Fatima Tous Romero, MD, Hospital 12 Universitario 12 de Octubre, Madrid, Spain; Carlota Gutierrez Garcıa- Rodrigo, MD, Hospital 12 Universitario 12 de Octubre, Madrid, Spain; Carlos Zarco Olivo, MD, Hospital 12 Universitario 12 de Octubre, Madrid, Spain; Francisco Vanaclocha Sebastian, MD, Hospital 12 Universitario 12 de Octubre, Madrid, Spain
Oral manifestations of syphilis: Clinical characteristics, differential diagnosis and serologic profile of patients with syphilis in the oral cavity Dimitrios Tsaknakis, MD, Department of Dermatology, University of Athens School of Medicine, A. Syggros Hospital, Athens, Greece; Electra Nicolaidou, MD, Department of Dermatology, University of Athens School of Medicine, A. Syggros Hospital, Athens, Greece; Christina Antoniou, MD, Department of Dermatology, University of Athens School of Medicine, A. Syggros Hospital, Athens, Greece; Sevasti Afantenou, MD, Department of Dermatology, University of Athens School of Medicine, A. Syggros Hospital, Athens, Greece; Eleni Gagari, DMD, Department of Dermatology, University of Athens School of Medicine, A. Syggros Hospital, Athens, Greece
Visceral leishmaniasis (VL) is an endemic parasitosis in India, East Africa, South America, the Mediterranean area, Central Asia and China. This infection is more prevalent in subjects with human immunodeficiency virus infection (HIV). The burden of HIV/leishmania coinfection is increasing in many developing countries; however, the effective antiretroviral therapy has led to a marked decrease in its incidence in Europe. A 40-year-old woman intravenous drug user and HIV positive was hospitalized in November of 2013 for a clinical picture characterized by fever, diarrhea and wasting. The cutaneous examination disclosed well-marginated nodules with firm consistence overlying the metacarpal and interphalangeal joints and following the path of the palmar aponeurosis. She had a previous history of VL diagnosed in 2011. The laboratory test showed pancytopenia and urine positive antigenuria for leishmaniasis. A biopsy of the nodules was performed where a dense infiltrate of macrophages in the dermis was observed with several amastigotes on hematoxylineeosin staining and on Giemsa staining. She was diagnosed with VL. She was treated with liposomal amphotericin B, suffering an allergic reaction. The treatment was changed to miltefosine, achieving a quick improvement with a complete clearance of the cutaneous lesions. The clinical features of VL in HIVpositive patients are often not classical and the cutaneous lesions attributed to leishmania are very seldom observed. The most frequent skin lesions in VL are macules, papules, plaques, nodules, and ulcers. Psoriasiform and dermatomyositislike eruptions have also been described. Nodule lesions have been extensively reported, however only 3 cases similar to ours have been described in the literature. In these cases, the nodules on the joints can be observed. Our case showed also nodules following the path of the palmar aponeurosis. This location has not been reported yet in the literature.
Syphilis is a sexually transmitted disease (STD) caused by Treponema pallidum that presents in primary, secondary and tertiary stages. Diagnosis of syphilis is often difficult as it may resemble a host of other disease entities and requires increased level of suspicion from the clinician as well as familiarization with the clinical manifestations of the disease. In particular, oral manifestations of syphilis may be very hard to diagnose. We present a case series of 12 patients diagnosed with secondary syphilis primarily from oral cavity lesions at the Oral Medicine Clinic of A. Syggros Hospital for Dermatologic and Venereal Diseases (1st University Clinic of Dermatology). Oral lesions were characterized by redness, erosions, lichenoid mucositis-like white patches, ulcers, and exophytic lesions, present for at least three weeks. The most common sites affected were palate and tongue, although all parts of the oral cavity may be affected. The majority of the patients had no skin lesions at the time of diagnosis which was rendered by serologic testing for VDRL, EIAIgG, EIAIgM and TPPA, after clinical evaluation of the oral cavity lesions raised the possibility of syphilis. Biopsy was performed in three cases, by the patient’s referring physician as a means to elucidate differential diagnosis prior to referral to our center. Histology in these cases demonstrated nonpathognomonic psoriasiform mucositis. Darkfield microscopy of the oral lesions is not recommended and was not performed, as oral microbial flora may produce a false positive result. Oral lesions resolved 2-3 weeks after administration of the appropriate treatment (penicillin G benzathine 2.4 million units IM) by the STD Clinic in our hospital. In summary, oral manifestations of syphilis are an important and difficult to diagnose aspect of a sexually transmitted disease that is on the rise. We present a comprehensive series of oral lesions of secondary syphilis so the dermatologist may be familiar with their characteristics.
Commercial support: None identified.
Commercial support: None identified.
1214
AB128
J AM ACAD DERMATOL
MAY 2015