Umbilicated erythematous papules in an immunocompromised patient

Abstract

A 53-year-old woman, with no notable medical history, presented with a non-pruritic rash after several months of weakness and low-grade fevers, 27 kg weight loss, and non-bloody productive cough. The rash was asymptomatic and had been present for 1 month on her legs and had spread to her chest and neck before presentation. Physical examination identifi ed multiple erythematous 2–3 mm well demarcated, non-tender, umbilicated papules on her upper chest, anterior neck, and anterior lower legs bilaterally (fi gure A). An HIV antibody test was positive and a CD4 cell count of 18 cells per μL was recorded. Skin biopsy results showed lobular capillary proliferation and primarily neutrophilic infl ammatory infi ltrate with Gram-negative rods within the cytoplasm of rare endothelial cells, consistent with bacillary angiomatosis (fi gure B). The patient’s lesions improved with 4 months of treatment with azithromycin 600 mg daily, combined with ethambutol 400 mg twice daily for coexisting Mycobacterium avium-intracellulare infection. For treatment of HIV, she began daily therapy with ritonavir 100 mg, atazanavir 300 mg, tenofovir 300 mg, and emtricitabine 200 mg. However, her CD4 cell count remained at fewer than 20 cells per μL and she died of respiratory failure, secondary to sepsis, 4 months after initial presentation. Bacillary angiomatosis is due to infection with Bartonella henselae or Bartonella quintana and is most often seen in immunocompromised individuals. It is typically seen in patients with AIDS with a CD4 cell count fewer than 100 cells per μL, but has also been reported in patients who have had transplant and those undergoing chemotherapy. It can occur as a single lesion or as multiple lesions. Bacillary angiomatosis usually presents as reddish-purple nodules or plaques and can often resemble Kaposi’s sarcoma. Bleeding and ulceration can occur. Diagnosis is typically made by histopathology; therefore, it is important to diff erentiate this disorder from other umbilicated lesions associated with immunosuppression, such as cryptococcosis or molluscum contagiosum. Patients can be treated with either macrolide or tetracycline antibiotics; however, a treatment duration of less than 3 months is associated with relapse.