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Unusual onset of Lyme borreliosis simulating herpes zoster
Letter
atosis and MF is attributed to Hallopeau and Bureau [7]. Since then, only a few such cases have been reported in the literature [8-lo]. All affected patients had advanced stages of cutaneous T-cell lymphoma, unlike our case who presented palmoplantar hyperkeratosis as the first clinical feature of MF. Differential diagnosis considered was Bazex syndrome and adult T-cell leukemia/lymphoma affecting tongue with cutaneous lesions of MF. However, our case did not show atypical cells in the excised tongue tonsils. In conclusion, we report a case with palmoplantar hyperkeratosis as the first symptom of MF unlike previously published cases where this occurred only in advanced stages of cutaneous T-cell lymphoma or SCzary syndrome. Francisco Russo *, Miguel Francisco Camacho Department of Medical Surgical University School of Medicine, 31075, Spain [l]
Ortega, Jose Carlos Moreno,
Dermatology AC&. Dr.
and Venereology, Fedriani 3, Seville
Voigtfinder V, Hartmann AA, Adam W, et al. Mycosis fungo]de: ttiologie innattendue d’un eczema chronique des mains avec gigantisme digital. Ann Dermatol Venereol 1988;115:1212-4.
Unusual onset of Lyme borreliosis simulating pes zoster
ber-
To the editor: Erythema (chronicum) migrans (EM) is a cardinal sign of early Lyme borreliosis (LB) and occurs in 60% to 80% of cases [1,2]. EM is sometimes associated with constitutional signs and symptoms, including arthralgias, myalgias, neck stiffness, lymphoadenopathy, fever, headache, chills, photophobia and disesthesias [l-3]. When the onset of LB is typical, the diagnosis is usually easy. However LB sometimes starts with larvate, largely incomplete or atypical manifestations similar to those of other diseases [4]. We report the case of an unusual onset of LB characterized by metamerical radiculitis initially wrongly mistaken for herpes zoster. In May 1994, a 63-year-old female presented with metameric, sub-continuous neuralgic pain started two weeks before, misinterpreted as herpes zoster and
to the editor [2] Robert A, Mark J, Donald M, John A. Ulceration of the palms and soles: an unusual feature of cutaneous T cell lymphoma. Acta Derm Venereol @to&h) 1990;70:523-5. [3] Wei N, Foon KA. Sclerodactyly in a patient with mycosis fungoides. Arch Intern Med 1985;145:139-40. [4] Garioch JJ, Todd P, Soukop M, Thomson J. T-Cell Lymphoma presenting with severe digital ischaemia. Clin Exp Dermatol 1991;16:202-3. [S] Moreno JC; Ortega M, Conejo-Mir JS; Sanchez Pedreho P. Palmoplantar pustulosis as a manifestation of cutaneous T cell Lymphoma (mycosis fungoides). J Am Acad Dermatol 1990;23:758-9. [6] Aractingi S, Robert C, Reygagne P, Verola 0, Dubertret L. Syndrome de SCzary avec lesions bulleuses palmo-plantaires. Ann Dermatol Venereol 1992;119:894-7. [7] Hallopeau H, Bureau G. Sur une erythrodermie mycosique avec hiperkeratose plantaire et palmaire et peut-etre neoplasie initiale. Bull Sot Dermatol 1896;7:222. [8] Tomsick RS: Hyperkeratosis in mycosis fungoides. Cutis 1982;29:621-3. [9] Thiers H, Moulin G, Racouchot J, Fayolle J, Perrot H. Etat hyperkdratosique paraneoplasique au tours d’un mycosis fong$de ganglionnaire secondaire d un parapsoriasis en plaques. Bull Sot Fr Dermatol Syphiliogr 1967;74:633-5. [lo] Homayoun A, Moshe 2. Palmoplantar hyperkeratosis in mycosis fungoides. J Am Acad Dermatol 1985;13:897-9.
* Corresponding
author.
Tel.: 954376474.
SSDI 0926-9959(95)00037-2
treated ineffectively with specific anti-viral therapy (intravenous acyclovir, 250 mg 3 times per day). She had a history of numerous tick bites; the last one had occurred two weeks before the onset of symptoms in her left upper thoracic paravertebral area. The patient described a sub-continuous severe burning sensation refractory to analgesics, localized in the lumbar region with a dermatomal distribution. This area resulted hyperpathic to mild touch. No other neurological signs were observed. On general medical examination three pale erythematous patches of 2 cm diameter, surrounded by normal appearing skin, were observed in the left lumbar area lying in the direction of the skin lines. Radiographic signs of a slight lumbar-sacral arthrosis were present. Renal ecography resulted negative. Routine laboratory parameters were completely normal. Serum samples were examined by both im-
Leffer
munofluorescence (IFA) and enzyme-linked immunosorbent assay (ELISA). Specific IgM antibodies to Borrelia burgdorferi were detected by IFA (1: 64) and by B. burgdogeri sonic extract ELISA. Specific IgG antibodies were not demonstrated by these two methods. High titres of specific IgM and low titres of IgG antibodies to B. burgdorferi were detected by flagellum ELISA. Serology confirmed the clinical suspicion of early neuroborreliosis, therefore the patient was treated with intravenous penicillin (10 million UI X 2/day for 12 days). The pale erythematous areas disappeared and the pain decreased dramatically within the third day of antibiotic therapy. The present case stresses that LB is a multisystem infectious disease capable of producing a wide variety of clinical pathologic conditions. Early neuroborreliosis is a rare, generally benign and self limiting condition. It usually starts about three weeks after a tick bite [5]. It can precede, follow or appear with EM, or it can be the only manifestation of early LB. The main pathological feature is Bannwarth’s Syndrome, a polytopic axonal radiculoneuritis with cranial nerve paresis, limb paresis, and radicular pain [6]. The latter may be the first and only symptom of Barmwarth’s Syndrome [5]. Therefore it is important to know this rare onset of LB to avoid wrong
fo the edifor
diagnosis. It is sometimes very difficult to identify EM, because of its atypical appearance or because it may be barely visible. Therefore the greatest care must be taken in the interpretation of borrelian serology when wishing to relate an unusual pathological manifestation to LB, particularly in endemic areas. Giuzto Nobile
Trevizan
l
, Giuseppe
Stinco,
Institute of Dermatology, Unioetsity nata, 34129 Triesfe, Italy
Patrizia
of Ttiesfe,
Cat&mar,
Ospeakle
Carla
di Caffi-
[l] Steere AC. Lyme disease. N EngI J Med 1989;321:586-96. [2] Trevisan G, Cinco M: Lyme disease: a general survey. Int J Dermatol 1990;29:1-8. [3] Asbrink E, Olsson I. Clinical manifestations of erythema chronicum migrans Afzelius in 161 patients: a comparison with Lyme disease. Acta Derm Venereal (Stockh) 1985;65:43-52. [4] Berger BW. Dermatologic manifestations of Lyme disease. Rev Infect Dis 1989;11(Suppl 6): S1475-81. [.5] Kristoferitsch W. Neurologic manifestations in Lyme borreliosis. CIin Dermatol 1992;11:393-400. [6] Finkel M. Lyme and its neurologic complications. Arch Neurol 1988:45:99-104. * Corresponding author. Tel. & Fax + 39-40-910415. SSDI 0926-9959(95)00038-O
atosis and MF is attributed to Hallopeau and Bureau [7]. Since then, only a few such cases have been reported in the literature [8-lo]. All affected patients had advanced stages of cutaneous T-cell lymphoma, unlike our case who presented palmoplantar hyperkeratosis as the first clinical feature of MF. Differential diagnosis considered was Bazex syndrome and adult T-cell leukemia/lymphoma affecting tongue with cutaneous lesions of MF. However, our case did not show atypical cells in the excised tongue tonsils. In conclusion, we report a case with palmoplantar hyperkeratosis as the first symptom of MF unlike previously published cases where this occurred only in advanced stages of cutaneous T-cell lymphoma or SCzary syndrome. Francisco Russo *, Miguel Francisco Camacho Department of Medical Surgical University School of Medicine, 31075, Spain [l]
Ortega, Jose Carlos Moreno,
Dermatology AC&. Dr.
and Venereology, Fedriani 3, Seville
Voigtfinder V, Hartmann AA, Adam W, et al. Mycosis fungo]de: ttiologie innattendue d’un eczema chronique des mains avec gigantisme digital. Ann Dermatol Venereol 1988;115:1212-4.
Unusual onset of Lyme borreliosis simulating pes zoster
ber-
To the editor: Erythema (chronicum) migrans (EM) is a cardinal sign of early Lyme borreliosis (LB) and occurs in 60% to 80% of cases [1,2]. EM is sometimes associated with constitutional signs and symptoms, including arthralgias, myalgias, neck stiffness, lymphoadenopathy, fever, headache, chills, photophobia and disesthesias [l-3]. When the onset of LB is typical, the diagnosis is usually easy. However LB sometimes starts with larvate, largely incomplete or atypical manifestations similar to those of other diseases [4]. We report the case of an unusual onset of LB characterized by metamerical radiculitis initially wrongly mistaken for herpes zoster. In May 1994, a 63-year-old female presented with metameric, sub-continuous neuralgic pain started two weeks before, misinterpreted as herpes zoster and
to the editor [2] Robert A, Mark J, Donald M, John A. Ulceration of the palms and soles: an unusual feature of cutaneous T cell lymphoma. Acta Derm Venereol @to&h) 1990;70:523-5. [3] Wei N, Foon KA. Sclerodactyly in a patient with mycosis fungoides. Arch Intern Med 1985;145:139-40. [4] Garioch JJ, Todd P, Soukop M, Thomson J. T-Cell Lymphoma presenting with severe digital ischaemia. Clin Exp Dermatol 1991;16:202-3. [S] Moreno JC; Ortega M, Conejo-Mir JS; Sanchez Pedreho P. Palmoplantar pustulosis as a manifestation of cutaneous T cell Lymphoma (mycosis fungoides). J Am Acad Dermatol 1990;23:758-9. [6] Aractingi S, Robert C, Reygagne P, Verola 0, Dubertret L. Syndrome de SCzary avec lesions bulleuses palmo-plantaires. Ann Dermatol Venereol 1992;119:894-7. [7] Hallopeau H, Bureau G. Sur une erythrodermie mycosique avec hiperkeratose plantaire et palmaire et peut-etre neoplasie initiale. Bull Sot Dermatol 1896;7:222. [8] Tomsick RS: Hyperkeratosis in mycosis fungoides. Cutis 1982;29:621-3. [9] Thiers H, Moulin G, Racouchot J, Fayolle J, Perrot H. Etat hyperkdratosique paraneoplasique au tours d’un mycosis fong$de ganglionnaire secondaire d un parapsoriasis en plaques. Bull Sot Fr Dermatol Syphiliogr 1967;74:633-5. [lo] Homayoun A, Moshe 2. Palmoplantar hyperkeratosis in mycosis fungoides. J Am Acad Dermatol 1985;13:897-9.
* Corresponding
author.
Tel.: 954376474.
SSDI 0926-9959(95)00037-2
treated ineffectively with specific anti-viral therapy (intravenous acyclovir, 250 mg 3 times per day). She had a history of numerous tick bites; the last one had occurred two weeks before the onset of symptoms in her left upper thoracic paravertebral area. The patient described a sub-continuous severe burning sensation refractory to analgesics, localized in the lumbar region with a dermatomal distribution. This area resulted hyperpathic to mild touch. No other neurological signs were observed. On general medical examination three pale erythematous patches of 2 cm diameter, surrounded by normal appearing skin, were observed in the left lumbar area lying in the direction of the skin lines. Radiographic signs of a slight lumbar-sacral arthrosis were present. Renal ecography resulted negative. Routine laboratory parameters were completely normal. Serum samples were examined by both im-
Leffer
munofluorescence (IFA) and enzyme-linked immunosorbent assay (ELISA). Specific IgM antibodies to Borrelia burgdorferi were detected by IFA (1: 64) and by B. burgdogeri sonic extract ELISA. Specific IgG antibodies were not demonstrated by these two methods. High titres of specific IgM and low titres of IgG antibodies to B. burgdorferi were detected by flagellum ELISA. Serology confirmed the clinical suspicion of early neuroborreliosis, therefore the patient was treated with intravenous penicillin (10 million UI X 2/day for 12 days). The pale erythematous areas disappeared and the pain decreased dramatically within the third day of antibiotic therapy. The present case stresses that LB is a multisystem infectious disease capable of producing a wide variety of clinical pathologic conditions. Early neuroborreliosis is a rare, generally benign and self limiting condition. It usually starts about three weeks after a tick bite [5]. It can precede, follow or appear with EM, or it can be the only manifestation of early LB. The main pathological feature is Bannwarth’s Syndrome, a polytopic axonal radiculoneuritis with cranial nerve paresis, limb paresis, and radicular pain [6]. The latter may be the first and only symptom of Barmwarth’s Syndrome [5]. Therefore it is important to know this rare onset of LB to avoid wrong
fo the edifor
diagnosis. It is sometimes very difficult to identify EM, because of its atypical appearance or because it may be barely visible. Therefore the greatest care must be taken in the interpretation of borrelian serology when wishing to relate an unusual pathological manifestation to LB, particularly in endemic areas. Giuzto Nobile
Trevizan
l
, Giuseppe
Stinco,
Institute of Dermatology, Unioetsity nata, 34129 Triesfe, Italy
Patrizia
of Ttiesfe,
Cat&mar,
Ospeakle
Carla
di Caffi-
[l] Steere AC. Lyme disease. N EngI J Med 1989;321:586-96. [2] Trevisan G, Cinco M: Lyme disease: a general survey. Int J Dermatol 1990;29:1-8. [3] Asbrink E, Olsson I. Clinical manifestations of erythema chronicum migrans Afzelius in 161 patients: a comparison with Lyme disease. Acta Derm Venereal (Stockh) 1985;65:43-52. [4] Berger BW. Dermatologic manifestations of Lyme disease. Rev Infect Dis 1989;11(Suppl 6): S1475-81. [.5] Kristoferitsch W. Neurologic manifestations in Lyme borreliosis. CIin Dermatol 1992;11:393-400. [6] Finkel M. Lyme and its neurologic complications. Arch Neurol 1988:45:99-104. * Corresponding author. Tel. & Fax + 39-40-910415. SSDI 0926-9959(95)00038-O