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Unusual presentation of a longstanding mucocutaneous leishmaniasis: A case report
5472
5804
Unilateral nipple eczema in a male teenager: Case report Ralph Vighi da Rosa, MD, Irmandade Santa Casa de Porto Alegre; Fernanda Musa Aguiar, MD, Irmandade Santa Casa de Porto Alegre; Ana Letıcia Boff, MD, Irmandade Santa Casa de Porto Alegre; Paulo Ricardo Martins de Souza, MD, Irmandade Santa Casa de Porto Alegre Background: Nipple eczema is an unusual presentation of many disease, especially when is unilateral, asymptomatic and in male patient. On that condition, it is important to do the correct diagnosis and to exclude malignancies. Case report: We report a case of a healthy 15-year-old teenager with a 4-month history of an acute eczema on the left nipple-areola complex. Episodic pruritic and exudation on the area were referred by the patient. He had a normal ultrasound requested previously by his pediatrician. In order to exclude Paget disease, a local biopsy was performed, with histology suggesting a chronic eczema. Immunochemistry was negative for malignancies. The diagnosis of chronic eczema was made and clobetasone cream twice a day for 30 days was prescribed. On review 4 weeks after treatment, there was considerable improvement of symptoms, with only a hyperpigmentation and a hypertrophy on the left nipple-areola complex. In order to Aesthetically Improve, as requested by the patient, a gentle curettage was done, with a satisfactory result.
Unusual presentation of a longstanding mucocutaneous leishmaniasis: A case report Jaclyn Guardia, Santo Tomas Hospital
Discussion: Nipple eczema is the most common manifestation of atopic dermatitis in young women. Clinically it mainly presents as arecurrent pruritic bilateral nipple eczema. Family history of atopy is also described. A unilateral eruption of the areola and nipple is an unusual presentation and can cause diagnostic confusion or raise concerns about a more serious condition, such as infection or Paget’s disease. The main differential diagnosis is allergic contact dermatitis, which commonly is bilateral, but different from the eczema, it frequently extends into the periareolar skin. Other differential diagnosis includes inflammatory dermatoses such as seborrheic dermatitis, dermatophyte infection and fixed drug eruptions. Paget’s disease of the nipple is an important diagnosis to be excluded. It presents as a thickened, sometimes pigmented, eczematoid, erythematous weeping or crusted lesion with irregular borders. Usually, the lesion is limited to the nipple or extended to the areola and is often associated with an underlying in situ or invasive carcinoma. Additional exams must be required, especially when ulceration or serous and/or bloody discharge are presented. We presented this case especially by its exuberant presentation in a male patient. Unilateral skin eruptions of the nipple at the young age are not common, but they exist in our daily clinical practice.
Leishmaniasis is an infection caused by Leishmania protozoans and transmitted by sand flies. The three major clinical forms are cutaneous, mucocutaneous and visceral, depending on the causative genus and the host immune response. In our region, mucocutaneous leishmaniasis is caused most often by Leishmania braziliensis. We describe an unusual case of an extensive ulcer involving most of the right foot causing bone destruction and associated nasal lesions as an atypical manifestation of a longstanding leishmaniasis. A 76-year-old male presented with a 20-year history of a progressive and extensive ulcer which was covered with granular, friable tissue and irregular tumor-like growth; involving the dorsal, lateral and medial sides of the right foot. Also, presented a depigmented scar in the anterior aspect of the lower third of the right leg surrounded by a brown pigmentation. The foot is shortened and widened, having a cuboid appearance. The nasal mucosa presented erythema and ulceration; along with destruction of the columella, drilling of the nasal septum and downfall of the nasal tip since 2 years ago. Among the clinical diagnosis were leishmaniasis and squamous cell carcinoma. Radiological examination revealed absence of the phalanges, partial loss of the fourth and fifth metatarsal and osteomyelitis. Histopathology of nasal and foot samples showed chronic granulomatous inflammatory infiltrate. Special stains were negative for microorganisms. The PCR revealed DNA fragments of leishmania in both locations. Cultures for leishmania were positive on the nose specimen. The patient underwent supracondylar amputation and received a total dose of 1.5 g of amphotericin B with good evolution. This case illustrates the importance of having a high index of suspicion of chronic ulceration in patients with the epidemiological background, characteristic scar and compatible histologic findings. Being that, when the infection persists for longer periods the diagnosis is more difficult to establish because the number of protozoa in the lesion decrease significantly. Also, reports an atypical presentation of a longstanding mucocutaneous leishmaniasis with a destructive bone involvement, rarely described in the literature. Commercial support: None identified.
Commercial support: None identified.
5435
Case Description: A 93-year-old male with history of multiply recurrent stage IIa superficial spreading-type melanoma on his right forearm presented to our clinic in April 2016 for re-excision of the lesion. Histopathology revealed residual MM invading the dermis and extending to all margins. Morphologically, the tumor cells showed balloon cell change and only minimal cytologic atypica. However, there was a lack of cell maturation, irregular staining with HMB-45, and loss of p16 expression consistent with a diagnosis of MM. Of note, the tumor exhibited a very peculiar pattern of dermal invasion. The melanoma cells infiltrated only areas of the dermis involved by SE fibers, and the SE band invaded by tumor was preserved without significant downward displacement or attenuation. Discussion: Preservation of the SE band with co-existing melanoma cells as presented here is an uncommon histologic finding in MM that may obscure accurate diagnosis, particularly in cases that lack overt atypia. Prior studies have suggested that displacement of the SE fibers likely relates to the great rapidity of development of MM compared to nevi. However, this case suggests that additional factors may be involved. The preferential involvement of the dermis with SE may be related to factors specific to cells of recurrent melanoma or satellitosis, or may be due to intrinsic properties of a highly elastotic dermis, such as altered mechanical resistance. Further studies that compare invasion of the SE band in primary tumors versus recurrent MM are needed to better characterize the atypical pattern of infiltration described here.
Unusual presentation of sebaceous glands carcinoma Giovana Fensterseifer, MD, Universidade Federal de Ci^encias da Sa ude de Porto Alegre; Fernanda Bonkevitch, MD, Santa Casa de Misericordia de Porto Alegre; Greice Rampon, MD, Private Clinic; Paulo Ricardo Martins Souza, MD, Santa Casa de Misericordia de Porto Alegre; Caroline Henkin, MD, Private Clinic Sebaceous glands carcinoma (SGC) is a rare tumor, comprising less than 1% of all malignant neoplasms of the skin. The main place of affection is the eyelid and it is more common in older men. We report a case of a patient whose gender and age are unusual for sebaceous carcinoma. Female, 48 years old, smoker for 14 years (8-10 cigarettes/day) and in treatment for hypertension, without personal or family history of previous malignancies. Patient referred right shoulder lesion with intermittent bleeding and mild pain with about a year of evolution. On examination: exophytic tumor with approximately 10 cm in diameter, hardened and painful on palpation, with ulcerated surface with purulent coating and surrounded by a band of neovascularization in the skin surface. Patient also reported gradual growth of the lesion, with multiple drainages held on primary health care services and use of several oral antibiotics. The patient was in good general health, without clinical or laboratorial signs of infection. The computerized tomography (CT) of the right shoulder showed well-defined lesion without calcification, or infiltration of muscle and bone tissues. Biopsy was consistent with sebaceous glands carcinoma. The complementary immunohistochemical examination showed positivity for pan-CK, BerEp4, p53, CK7, androgen receptor, EMA, p63 and Ki-67 positive in about 10% of neoplastic cells. The investigation of protein expression of DNA repair genes showed positivity for MLH-1, MSH-2, and PMS2; and negativity for MLH-2. The patient underwent chest CT and abdominal CT without evidence of focal or metastatic lesions. After approximately 30 days, the patient underwent a surgical procedure. The anatomopathological description of the piece described surgical borders without signs of vascular or perineural invasion. GSC is a rare tumor, clinically described as a single tumor mass, firm, covered with normal or slightly warty skin. The scalp and face are the most affected areas and the eyelid is its most common site. In a review of the database of ‘‘Surveillance, Epidemiology and End Results’’ (SEER) from 1973 to 2004, only 1349 cases were identified. According to our review, this is the first extraocular event reported in Brazil. Azevedo et al, described four cases in our country, but all with ocular involvement and all cases are between the ages of 50-75 years. Similar findings were exposed by Vianna et al in their work presenting a series of three cases, all with ocular involvement. These data, unlike the case we reported above, agrees with the epidemiology of the disease so far known. Regarding extraocular SGC, it is more often found in head and neck areas and is more associated with Muir- Torre syndrome than periocular SGC. It is not known for sure if there is need for staging patients with SGC, as there are few cases reported in the literature. However, metastases are frequent and early excision is necessary.
Commercial support: None identified.
Commercial support: None identified.
5389 Unusual pattern of infiltration of solar elastosis in recurrent malignant melanoma Tyler Menge, MD, Saint Joseph Mercy Health System; Alison Durham, MD, University of Michigan Health System; Douglas Fullen, MD, University of Michigan Health System; Aleodor Andea, MD, University of Michigan Health System Introduction: Numerous diagnostic criteria have been proposed to assist in accurate recognition of malignant melanoma (MM). In the context of chronically sundamaged skin with solar elastosis (SE), several authors have observed significant downward displacement or attenuation of the SE band in MM, whereas the SE fiber network is preserved and tends to co-exist with melanocytes of benign nevi. Here we report a case of confirmed MM with a pattern of SE infiltration more characteristic of a benign nevus.
AB274
J AM ACAD DERMATOL
JUNE 2017
5804
Unilateral nipple eczema in a male teenager: Case report Ralph Vighi da Rosa, MD, Irmandade Santa Casa de Porto Alegre; Fernanda Musa Aguiar, MD, Irmandade Santa Casa de Porto Alegre; Ana Letıcia Boff, MD, Irmandade Santa Casa de Porto Alegre; Paulo Ricardo Martins de Souza, MD, Irmandade Santa Casa de Porto Alegre Background: Nipple eczema is an unusual presentation of many disease, especially when is unilateral, asymptomatic and in male patient. On that condition, it is important to do the correct diagnosis and to exclude malignancies. Case report: We report a case of a healthy 15-year-old teenager with a 4-month history of an acute eczema on the left nipple-areola complex. Episodic pruritic and exudation on the area were referred by the patient. He had a normal ultrasound requested previously by his pediatrician. In order to exclude Paget disease, a local biopsy was performed, with histology suggesting a chronic eczema. Immunochemistry was negative for malignancies. The diagnosis of chronic eczema was made and clobetasone cream twice a day for 30 days was prescribed. On review 4 weeks after treatment, there was considerable improvement of symptoms, with only a hyperpigmentation and a hypertrophy on the left nipple-areola complex. In order to Aesthetically Improve, as requested by the patient, a gentle curettage was done, with a satisfactory result.
Unusual presentation of a longstanding mucocutaneous leishmaniasis: A case report Jaclyn Guardia, Santo Tomas Hospital
Discussion: Nipple eczema is the most common manifestation of atopic dermatitis in young women. Clinically it mainly presents as arecurrent pruritic bilateral nipple eczema. Family history of atopy is also described. A unilateral eruption of the areola and nipple is an unusual presentation and can cause diagnostic confusion or raise concerns about a more serious condition, such as infection or Paget’s disease. The main differential diagnosis is allergic contact dermatitis, which commonly is bilateral, but different from the eczema, it frequently extends into the periareolar skin. Other differential diagnosis includes inflammatory dermatoses such as seborrheic dermatitis, dermatophyte infection and fixed drug eruptions. Paget’s disease of the nipple is an important diagnosis to be excluded. It presents as a thickened, sometimes pigmented, eczematoid, erythematous weeping or crusted lesion with irregular borders. Usually, the lesion is limited to the nipple or extended to the areola and is often associated with an underlying in situ or invasive carcinoma. Additional exams must be required, especially when ulceration or serous and/or bloody discharge are presented. We presented this case especially by its exuberant presentation in a male patient. Unilateral skin eruptions of the nipple at the young age are not common, but they exist in our daily clinical practice.
Leishmaniasis is an infection caused by Leishmania protozoans and transmitted by sand flies. The three major clinical forms are cutaneous, mucocutaneous and visceral, depending on the causative genus and the host immune response. In our region, mucocutaneous leishmaniasis is caused most often by Leishmania braziliensis. We describe an unusual case of an extensive ulcer involving most of the right foot causing bone destruction and associated nasal lesions as an atypical manifestation of a longstanding leishmaniasis. A 76-year-old male presented with a 20-year history of a progressive and extensive ulcer which was covered with granular, friable tissue and irregular tumor-like growth; involving the dorsal, lateral and medial sides of the right foot. Also, presented a depigmented scar in the anterior aspect of the lower third of the right leg surrounded by a brown pigmentation. The foot is shortened and widened, having a cuboid appearance. The nasal mucosa presented erythema and ulceration; along with destruction of the columella, drilling of the nasal septum and downfall of the nasal tip since 2 years ago. Among the clinical diagnosis were leishmaniasis and squamous cell carcinoma. Radiological examination revealed absence of the phalanges, partial loss of the fourth and fifth metatarsal and osteomyelitis. Histopathology of nasal and foot samples showed chronic granulomatous inflammatory infiltrate. Special stains were negative for microorganisms. The PCR revealed DNA fragments of leishmania in both locations. Cultures for leishmania were positive on the nose specimen. The patient underwent supracondylar amputation and received a total dose of 1.5 g of amphotericin B with good evolution. This case illustrates the importance of having a high index of suspicion of chronic ulceration in patients with the epidemiological background, characteristic scar and compatible histologic findings. Being that, when the infection persists for longer periods the diagnosis is more difficult to establish because the number of protozoa in the lesion decrease significantly. Also, reports an atypical presentation of a longstanding mucocutaneous leishmaniasis with a destructive bone involvement, rarely described in the literature. Commercial support: None identified.
Commercial support: None identified.
5435
Case Description: A 93-year-old male with history of multiply recurrent stage IIa superficial spreading-type melanoma on his right forearm presented to our clinic in April 2016 for re-excision of the lesion. Histopathology revealed residual MM invading the dermis and extending to all margins. Morphologically, the tumor cells showed balloon cell change and only minimal cytologic atypica. However, there was a lack of cell maturation, irregular staining with HMB-45, and loss of p16 expression consistent with a diagnosis of MM. Of note, the tumor exhibited a very peculiar pattern of dermal invasion. The melanoma cells infiltrated only areas of the dermis involved by SE fibers, and the SE band invaded by tumor was preserved without significant downward displacement or attenuation. Discussion: Preservation of the SE band with co-existing melanoma cells as presented here is an uncommon histologic finding in MM that may obscure accurate diagnosis, particularly in cases that lack overt atypia. Prior studies have suggested that displacement of the SE fibers likely relates to the great rapidity of development of MM compared to nevi. However, this case suggests that additional factors may be involved. The preferential involvement of the dermis with SE may be related to factors specific to cells of recurrent melanoma or satellitosis, or may be due to intrinsic properties of a highly elastotic dermis, such as altered mechanical resistance. Further studies that compare invasion of the SE band in primary tumors versus recurrent MM are needed to better characterize the atypical pattern of infiltration described here.
Unusual presentation of sebaceous glands carcinoma Giovana Fensterseifer, MD, Universidade Federal de Ci^encias da Sa ude de Porto Alegre; Fernanda Bonkevitch, MD, Santa Casa de Misericordia de Porto Alegre; Greice Rampon, MD, Private Clinic; Paulo Ricardo Martins Souza, MD, Santa Casa de Misericordia de Porto Alegre; Caroline Henkin, MD, Private Clinic Sebaceous glands carcinoma (SGC) is a rare tumor, comprising less than 1% of all malignant neoplasms of the skin. The main place of affection is the eyelid and it is more common in older men. We report a case of a patient whose gender and age are unusual for sebaceous carcinoma. Female, 48 years old, smoker for 14 years (8-10 cigarettes/day) and in treatment for hypertension, without personal or family history of previous malignancies. Patient referred right shoulder lesion with intermittent bleeding and mild pain with about a year of evolution. On examination: exophytic tumor with approximately 10 cm in diameter, hardened and painful on palpation, with ulcerated surface with purulent coating and surrounded by a band of neovascularization in the skin surface. Patient also reported gradual growth of the lesion, with multiple drainages held on primary health care services and use of several oral antibiotics. The patient was in good general health, without clinical or laboratorial signs of infection. The computerized tomography (CT) of the right shoulder showed well-defined lesion without calcification, or infiltration of muscle and bone tissues. Biopsy was consistent with sebaceous glands carcinoma. The complementary immunohistochemical examination showed positivity for pan-CK, BerEp4, p53, CK7, androgen receptor, EMA, p63 and Ki-67 positive in about 10% of neoplastic cells. The investigation of protein expression of DNA repair genes showed positivity for MLH-1, MSH-2, and PMS2; and negativity for MLH-2. The patient underwent chest CT and abdominal CT without evidence of focal or metastatic lesions. After approximately 30 days, the patient underwent a surgical procedure. The anatomopathological description of the piece described surgical borders without signs of vascular or perineural invasion. GSC is a rare tumor, clinically described as a single tumor mass, firm, covered with normal or slightly warty skin. The scalp and face are the most affected areas and the eyelid is its most common site. In a review of the database of ‘‘Surveillance, Epidemiology and End Results’’ (SEER) from 1973 to 2004, only 1349 cases were identified. According to our review, this is the first extraocular event reported in Brazil. Azevedo et al, described four cases in our country, but all with ocular involvement and all cases are between the ages of 50-75 years. Similar findings were exposed by Vianna et al in their work presenting a series of three cases, all with ocular involvement. These data, unlike the case we reported above, agrees with the epidemiology of the disease so far known. Regarding extraocular SGC, it is more often found in head and neck areas and is more associated with Muir- Torre syndrome than periocular SGC. It is not known for sure if there is need for staging patients with SGC, as there are few cases reported in the literature. However, metastases are frequent and early excision is necessary.
Commercial support: None identified.
Commercial support: None identified.
5389 Unusual pattern of infiltration of solar elastosis in recurrent malignant melanoma Tyler Menge, MD, Saint Joseph Mercy Health System; Alison Durham, MD, University of Michigan Health System; Douglas Fullen, MD, University of Michigan Health System; Aleodor Andea, MD, University of Michigan Health System Introduction: Numerous diagnostic criteria have been proposed to assist in accurate recognition of malignant melanoma (MM). In the context of chronically sundamaged skin with solar elastosis (SE), several authors have observed significant downward displacement or attenuation of the SE band in MM, whereas the SE fiber network is preserved and tends to co-exist with melanocytes of benign nevi. Here we report a case of confirmed MM with a pattern of SE infiltration more characteristic of a benign nevus.
AB274
J AM ACAD DERMATOL
JUNE 2017