Atypical Cutaneous Lesions Research Articles

Navigating the complexities: a case report on the varied presentation of lupus vulgaris

A 16-year-old female presented with an asymptomatic lesion in the right axilla, evolving over six months into a scaly, erythematous to brownish-colored plaque with associated axillary lymphadenopathy. Routine investigations revealed mild anemia, elevated erythrocyte sedimentation rate (ESR), and a positive Mantoux test. Histopathological examination confirmed lupus vulgaris, characterized by tuberculoid granulomas within the superficial dermis. Treatment with anti-tubercular therapy led to significant lesion improvement. Lupus vulgaris, a form of cutaneous tuberculosis, presents varied clinical features and poses diagnostic challenges. Early recognition and prompt treatment are essential to prevent morbidity and scarring. This case highlights the importance of considering lupus vulgaris in differential diagnosis of atypical cutaneous lesions, contributing to better disease management and reduced morbidity.

Case Report: Fever of unknown origin caused by type Ⅱ lepra reaction

We report an ethnic minority patient presenting as fever of unknown origin for over 25 days, who was admitted with atypical cutaneous lesions, damages in the peripheral joints and nervous system. Owing to tracing the past medical history, the patient has received a prompt diagnosis and achieved good outcome. By summarizing the entire diagnosis and treatment process, we report the case to deepen the understanding of fever of unknown origin caused by type Ⅱ lepra reaction. All specialties, meanwhile, should be aware of the rare infectious diseases in daily medical practice.

Niet-genezende huidletsels van de borst

Non-healing skin lesions in the right mammary region Although almost all dermatological conditions are visible, some patients wait a long time to consult a dermatologist. Nevertheless, an early diagnosis is important for the treatment and prognosis in case of cutaneous cancers. A 39-year-old man with skin lesions on his right chest, present for 3 years and slowly growing over time, consulted the dermatologist. The anatomopathological examination showed a diffuse-type primary cutaneous follicular B-cell non-Hodgkin lymphoma. Staging revealed a primary cutaneous lymphoma. After deliberation in a multidisciplinary oncologic consultation, radiotherapy was started. Cutaneous lymphomas are often difficult to diagnose because of their non-specific and variable clinical presentation. Skin biopsies should be performed when patients present with atypical cutaneous lesions. In case of cutaneous B-cell lymphomas, early diagnosis is important to detect and treat an underlying systemic or aggressive B-cell lymphoma. A multidisciplinary management team including dermatologists, pathologists, hematologists and radiation oncologists is necessary.

Heterogeneous cutaneous findings associated with intrauterine HSV infection: A case series and literature review.

Herpes simplex virus (HSV) infection acquired in utero may present with non-vesicular dermatologic findings in affected newborns, which may pose a diagnostic dilemma. We aimed to describe and assess the range of non-vesiculobullous skin lesions that neonates with intrauterine HSV infection may manifest at birth. We collected a multicenter case series and conducted a literature review of neonates with intrauterine HSV infection presenting with non-vesiculobullous cutaneous lesions. Twenty-two cases were reviewed, including six managed clinically by members of our team and 16 identified in the literature. Four (18%) were associated with twin pregnancies, and thirteen (59%) cases occurred in premature infants. Only four (18%) mothers had a documented history of HSV infection. Twelve (55%) cases resulted in poor outcomes, including long-term neurologic sequelae or death. Cutaneous manifestations included erosions, ulcerations, crusted papules or plaques, calcinosis cutis, excoriations, macules (erythematous, hypopigmented, or hyperpigmented), cutaneous atrophy, contractures, and bruising. About one-third of neonates developed new-onset vesicular lesions within a week of birth; in each of these cases, accurate diagnosis and therapy were delayed until appearance of vesicles. The range of dermatologic findings associated with intrauterine HSV is extremely broad, and the various morphologies present at birth likely reflect different stages of the ongoing evolution of an HSV infection that began in utero. Clinicians should have a low threshold for HSV testing in premature neonates born with atypical cutaneous lesions, since early detection and treatment of HSV may reduce morbidity and mortality from systemic complications.

Transplant-associated penile Kaposi sarcoma managed with single agent paclitaxel chemotherapy: a case report

BackgroundKaposi’s sarcoma is an uncommon complication in renal transplant patients, and typically presents with cutaneous lesions on the lower extremities. Penile involvement has been reported only rarely. Management of cutaneous-limited disease is primarily reduction of immunosuppression and conversion to an mTOR-inhibitor, whereas the treatment of disseminated disease in transplant patients is more variable.Case presentationA 75-year-old male, originally from Somalia, received a deceased-donor kidney transplant for diabetic and hypertensive nephropathy. Seven months post-transplant he presented with lower limb lesions, oedema and bilateral deep vein thromboses. He then developed a fast-growing painful lesion on his penile shaft. A biopsy of this lesion confirmed KS, and a PET scan demonstrated disseminated disease in the lower extremities, penis and thoracic lymph nodes. His tacrolimus was converted to sirolimus, and his other immunosuppression was reduced. He was treated with single agent paclitaxel chemotherapy in view of his rapidly progressing, widespread disease. The penile lesion completely resolved, and the lower extremity lesions regressed significantly. His kidney allograft function remained stable throughout treatment.ConclusionThis case illustrates a rare presentation of an uncommon post-transplant complication and highlights the need for a high index of suspicion of KS in transplant patients presenting with atypical cutaneous lesions. It serves to demonstrate that the use of single agent paclitaxel chemotherapy, switch to an mTORi and reduction in immunosuppression where possible produces excellent short-term outcomes, adding to the body of evidence for this management strategy in disseminated Kaposi’s sarcoma.

Diabetes Modifies the Clinic Presentation of Cutaneous Leishmaniasis.

BackgroundCutaneous leishmaniasis (CL) caused by L. braziliensis is characterized by 1 or multiple well-limited ulcerated lesions. Diabetes mellitus (DM) impairs neutrophil and monocyte function, and there is a report of vegetative lesions in a patient with both diseases in Morocco. Here we evaluate the influence of DM on clinical manifestations, immune response, and in the treatment of CL. MethodsThe participants were 36 DM patients with CL and 36 patients with CL without DM, matched by age and gender. The diagnosis of CL was performed by documentation of DNA of L. braziliensis by polymerase chain reaction in the lesion biopsy and histopathologic findings. All patients were treated with Glucantime (Sanofi-Aventis) 20 mg/kg of weight per day for 20 days. ResultsThere was no difference in the majority of the clinical variables between the groups, and the cure rate in patients with CL and DM (67%) was similar to that observed in CL patients (56%; P ˃ .05). The most important finding was the documentation that 36% of the patients with DM and CL had atypical cutaneous lesions characterized by large superficial ulcers without defined borders. High levels of interferon-γ, tumor necrosis facor, and interleukin-1β were detected in the supernatants of mononuclear cells stimulated with Leishmania antigen in patients with DM and atypical CL. Moreover, while cure was observed in only 33% of the patients with DM and atypical CL lesions, it was observed in 85% of patients with typical lesions (P < .05). ConclusionsDM modifies the clinical presentation of CL, enhances pro-inflammatory cytokine production, and impairs response to antimony therapy.

Leishmania braziliensis: Strain-Specific Modulation of Phagosome Maturation.

Leishmania (Viannia) braziliensis is responsible for the largest number of American tegumentary leishmaniasis (ATL) in Brazil. ATL can present several clinical forms including typical (TL) and atypical (AL) cutaneous and mucocutaneous (ML) lesions. To identify parasite and host factors potentially associated with these diverse clinical manifestations, we first surveyed the expression of two virulence-associated glycoconjugates, lipophosphoglycan (LPG) and the metalloprotease GP63 by a panel of promastigotes of Leishmania braziliensis (L. braziliensis) strains isolated from patients with different clinical manifestations of ATL and from the sand fly vector. We observed a diversity of expression patterns for both LPG and GP63, which may be related to strain-specific polymorphisms. Interestingly, we noted that GP63 activity varies from strain to strain, including the ability to cleave host cell molecules. We next evaluated the ability of promastigotes from these L. braziliensis strains to modulate phagolysosome biogenesis in bone marrow-derived macrophages (BMM), by assessing phagosomal recruitment of the lysosome-associated membrane protein 1 (LAMP-1) and intraphagosomal acidification. Whereas, three out of six L. braziliensis strains impaired the phagosomal recruitment of LAMP-1, only the ML strain inhibited phagosome acidification to the same extent as the L. donovani strain that was used as a positive control. While decreased phagosomal recruitment of LAMP-1 correlated with higher LPG levels, decreased phagosomal acidification correlated with higher GP63 levels. Finally, we observed that the ability to infect and replicate within host cells did not fully correlate with the inhibition of phagosome maturation. Collectively, our results revealed a diversity of strain-specific phenotypes among L. braziliensis isolates, consistent with the high genetic diversity within Leishmania populations.

Implementación de un PCR-RFLP/Hsp70 para identificar y tipificar especies de Leishmania en una zona endémica a Leishmaniasis Cutánea Atípica en Honduras

Introducción. La leishmaniasis cutánea atípica es una variante no ulcerada de la leishmaniasis cutánea producida por Leishmania (L.) infantum. En Honduras está presente en los departamentos de La Paz, Francisco Morazán, Choluteca, El Paraíso y Valle. El espectro clínico incluye lesiones cutáneas menores a 10 mm y benignas hasta afecciones viscerales que pueden comprometer la vida del paciente. El objetivo del presente estudio fue implementar una técnica de biología molecular para la detección y tipificación de Leishmania spp en individuos con lesiones sospechosas a leishmaniasis cutánea atípica. Metodología. Para la implementación se usó ADN de cepas de referencia: Leishmania (L.) infantum chagasi, Leishmania (L.) mexicana, Leishmania (V.) panamensis, Leishmania (V.) braziliensis con un producto esperado de 1200 pares de base (pb). Se utilizaron las enzimas de restricción Hae III, BccI, RsaI y Mlul para la identificación de especies del género Leishmania. Se seleccionaron muestras clínicas (frotis en lámina) de los departamentos de Francisco Morazán y Valle. El estudio fue sometido al comité de ética de la Maestría en Enfermedades Infecciosas y Zoonóticas. Resultados: Se analizaron 39 muestras (27 de Francisco Morazán y 12 Valle). Se identificó a Leishmania (L.) infantum en el 100% de las muestras (29/29). Conclusiones/Recomendaciones: Se demostró que el polimorfismo del gen hsp70 junto con la digestión enzimática (RFLP) proporciona buenos resultados en la amplificación de parásitos a partir de muestras en lámina agilizando así el proceso de identificación molecular. Siendo una herramienta útil para tipificar especies de Leishmania spp en zonas donde prevalece más de una especie del parasito. Se recomienda realizar una vigilancia epidemiológica constante, para lograr determinar el comportamiento geográfico de las especies de Leishmania.

Atypical Cutaneous Manifestations of Mucormycosis Infection in Immunocompromised Hosts—Review Article

Abstract Mucormycosis is a rare invasive, rapidly spreading life-threatening fungal infection caused by mucorales species. Primary cutaneous mucormycosis occurs due to direct inoculation of the mold into the skin, whereas secondary cutaneous mucormycosis occurs due to hematogenous dissemination from the primary site of infection to the skin. Disruption of skin continuity is the portal entry for mucorales species in primary cutaneous mucormycosis. Immunosuppression conditions increase the risk of cutaneous mucormycosis infection. We present unusual cases of cutaneous mucormycosis that resulted from penetration of the perineum region by mucorales species in stool that was associated with fecal incontinence and progression to a black necrotic ulcer. These lesions look similar to ecthyma gangrenosum, atypical cutaneous herpes lesions, and decubitus ulcers. It is difficult to differentiate on a clinical basis alone. Early diagnosis and treatment are crucial steps to prevent complications of cutaneous mucormycosis infection.

Carcinoma de células escamosas pigmentado. Descripción de un caso y revisión de la literatura

The majority of pigmented cutaneous tumours are melanocytic, although there are other epithelial entities that are clinically similar, such as pigmented squamous cell carcinoma. We report the case of a 78 year old man who presented with a pigmented lesion on the left temple, clinically and dermoscopically suspicious of melanoma. After complete excision the lesion was seen to have infiltrating atypical squamous proliferation, with numerous mitoses and several associated stromal melanophages. Immunohistochemical studies revealed a dendritic melanocytic population, arranged in an intratumoral homogeneous reticular pattern, without mass or sheet formation or significant cytological atypia. These features rule out a malignant biphasic squamo-melanocytic lesion, based on the absence of malignant criteria in the melanocytic component. Pigmented squamous cell carcinoma is a rare variant of cutaneous squamous cell carcinoma but should be considered in the differential diagnosis of pigmented atypical cutaneous lesions, especially of melanoma and squamo-melanocytic tumour.

LEISHMANIOSE CUTÂNEA E PANCITOPENIA COMO APRESENTAÇÃO INICIAL DE INFECÇÃO PELO HIV

A leishmaniose é uma doença infecciosa causada por espécies de Leishmania. A leishmaniose cutânea manifesta-se por pápulas que evoluem para nódulos/placas com ulceração. O diagnóstico é essencialmente clínico, podendo ser confirmado através de biópsia cutânea. Nos doentes HIV positivos há uma maior propensão ao desenvolvimento de leishmaniose visceral, bem como ao aparecimento de lesões cutâneas atípicas. Descrevemos o caso clínico de um doente com leishmaniose cutânea e pancitopenia cuja investigação conduziu ao diagnóstico de uma infecção pelo HIV previamente desconhecida. Um doente do sexo masculino é observado com 2 lesões nodulares ulceradas na face com 6 meses de evolução. Suspeitou-se clinicamente de leishmaniose cutânea, confirmado por biópsia cutânea. Introduziu-se itraconazol, com regressão completa das lesões. O doente referia também astenia, anorexia e perda de peso, pelo que se efectuou estudo complementar, que revelou pancitopenia e infiltração esplénica. Foram realizadas serologias virais, que conduziram ao diagnóstico adicional de infecção pelo HIV1.

Primary Cutaneous γδ T-Cell Lymphoma and Hemophagocytic Syndrome.

Primary cutaneous γδ T-cell lymphoma and hemophagocytic syndrome (HPS) is a very rare disease process with only 41 cases of this type of lymphoma published to date. We report the case of a 56-year-old woman who developed high-grade fevers and multiple nonhealing bilateral lower extremity ulcers associated with a recent diagnosis of Ackerman syndrome. Multiple lesion biopsies yielded a differential diagnosis including sarcoidosis and lupus panniculitis. Each biopsy site developed into a poorly healing wound. After extensive rheumatologic and dermatologic workup, failed courses of hyperbaric oxygen and corticosteroids, and the development of worsening fevers, the diagnosis of γδ T-cell lymphoma was made. The objective of this article was to illustrate a very rare case of a rapidly progressing cutaneous lymphoma while stressing the importance of a surgical approach to nonhealing wounds and biopsy in chronic wounds.An aggressive multidisciplinary approach including infectious disease, hematology/oncology, nephrology, plastic surgery, and interventional pulmonology was used. Medical approaches included several courses of corticosteroids and antineoplastics. Our surgical approach included numerous excision and debridements of her nonhealing ulcers with removal of necrotic tissue. It also included placement of cadaveric epidermal graft, and bovine tendon collagen cross-linked with glycosaminoglycans with a silicone matrix bilayer (Integra, Plainsboro, NJ) combined with multiple local myocutaneous advancement flaps. This approach demonstrated clinical improvement in wound healing. Pathological examination of several lesions included immunohistochemistry staining, flow cytometry, and molecular studies.The diagnosis of primary cutaneous γδ T-cell lymphoma was made based on a pathology specimen. Subsequent imaging showed numerous pulmonary nodules later determined to be pulmonary Aspergillosis. Additionally, she developed a constellation of clinical and laboratory features defined as the HPS. Despite medical therapy and improved wound healing, she died to seizures that left her comatose, thought to be secondary to central nervous system advancement of her HPS. The patient eventually died after care was withdrawn.Cutaneous forms of lymphoma must be considered in the differential diagnosis of atypical cutaneous lesions or nonhealing wounds. There should be no delay in performing a skin biopsy to obtain a tissue diagnosis. A surgical approach to wounds clearly demonstrates improved wound healing.

Sífilis maligna en un paciente con infección por VIH: Presentación de un caso y revisión de la literatura

Malignant syphilis is a rare form of secondary syphilis strongly associated with human immunodeficiency virus infection (HIV). This clinical form of the disease is characterized by atypical cutaneous ulcerative and disseminated lesions and systemic compromise that can delay the final diagnosis. There are only few reports in the medical literature about malignant lues in HIV-infected patients. Malignant syphilis should be considered in the differential diagnosis in HIV-infected patients with fever and ulcerative skin lesions. Here we describe a man who developed clinical cutaneous and systemic manifestations pathologically confirmed as malignant syphilis and we performed a review of the literature.

Atypical Lesions as a Sign of Cutaneous Dissemination of Visceral Leishmaniasis in a Human Immunodeficiency Virus–Positive Patient Simultaneously Infected by Two Viscerotropic Leishmania Species

Leishmaniasis is considered an emerging opportunistic disease in human immunodeficiency virus (HIV)-infected patients who have considerably variable clinical presentation. We report a patient with visceral leishmaniasis who had unexpected clinical aspects (atypical cutaneous lesions appearing after long-term evidence of visceral parasites). The patient had hepatoesplenomegaly in the absence of fever, but was otherwise generally healthy. The HIV viral load was low despite severe immunossupression (low lymphocyte proliferation and low level of interferon-γ, concomitant with a high lymphocyte activation status). Surprisingly, two Leishmania strains were isolated from his bone marrow (typical L. infantum sequence MON-1, type A) and skin (L. donovani MON-2 sequence); this second strain had not been previously identified in Brazil. The association of visceral leishmaniasis and HIV/acquired immunodeficiency syndrome is a largely unknown disease, particularly in areas in which leishmaniasis is not endemic. Such atypical cases indicate that this disease can be undiagnosed in clinical settings.

Ulcerating Molluscum Contagiosum in a Boy With Relapsed Acute Lymphoblastic Leukemia

Molluscum contagiosum is an infectious disease presenting with flesh-colored, dome-shaped, umblicated papules. A few atypical presentations have been reported in immunodeficient patients. A 5-year-old boy with acute lymphoblastic leukemia, presented with bright white-colored papular lesions with no umblications on the chin during his continuation chemotherapy. Increased number of the lesions covered almost his entire chin in months. Topical therapies did not improve the lesions. After his bone marrow relapse, induction chemotherapy was withheld because of bronchopneumonia after febrile neutropenia. After initiation of a combination of systemic parenteral antibiotic and antifungal therapies, his parents squeezed one of his papular lesions. Meanwhile, systemic acyclovir was added to his therapy, because of herpes labialis. Despite the large spectrum of his therapies, in 1.5 months, this small lesion progressed to a large lesion with erythematous ground and a central ulceration. Etiology of the lesion could not be enlightened until a skin biopsy that was compatible with the molluscum contagiosum. A partial resolution was achieved by cryotherapy. In conclusion, molluscum contagiosum may present as an ulcerating lesion during childhood leukemia treatment. A skin biopsy should be performed for the accurate diagnosis of atypical cutaneous lesions in immunocompromised patients.

Atypical cutaneous lesions of penicillium marneffei infection as a manifestation of the immune reconstitution inflammatory syndrome after highly active antiretroviral therapy

Penicillium marneffei infections normally manifest as molluscum contagiosum like skin lesion in HIV-infected persons. We report a case with verrucous lesions over nose and face due to Penicillium marneffei infection after HAART treatment. A 28-year-old man presented, after two weeks of HAART treatment, with multiple erythematous, scaly, papules and nodules with central necrosis predominantly in face and both extremities and scrotum. Microbiological investigations confirmed the diagnosis of Penicillium marneffei infection. This is perhaps the first case report with such manifestation due to Penicillium marneffei infection.

One-Stage Integra reconstruction in head and neck defects

Integra dermal regeneration template - a two-stage, tissue-engineered, artificial skin - was introduced in the UK in May 1996. There were no restrictions on clinical application and a series of applications in reconstructive surgery were undertaken. One case involved a Caucasian lady with a nose tip basal cell carcinoma (BCC) who had a single-stage reconstruction. The 6-year follow-up was remarkable as it showed a scarless repair. We undertook a clinical evaluation to explore the outcome of one-stage Integra reconstruction in a selected series of Chinese patients. Ten patients (five male and five female; age range: 54-86 years) with complicated or atypical cutaneous lesions involving the head and neck were treated in an outpatient setting. Pathology revealed eight BCCs, one squamous cell carcinoma (SCC) and one seborrhoeic keratosis. Healing took place either by wound contraction alone or in conjunction with re-epithelialisation. All wounds were fully healed within 6 weeks. Follow-up ranged from 18 to 30 months, and there has been no recurrence of the malignant lesions. In selected cases, one-stage reconstruction using Integra can reduce operating time with no delay for frozen section, flap raising or graft harvesting. More immediate postoperative care is needed, but the long-term aesthetic results are uniformly acceptable.

Herpes simplex vegetans: atypical genital herpes infection with prominent plasma cell infiltration in B‐cell chronic lymphocytic leukemia

Herpes simplex vegetans is a rare disorder even in immunocompromised patients. It typically affects patients with HIV or myeloproliferative diseases.The atypical cutaneous lesions show papillomatous vegetations in varying locations. Histologically the lesions show pseudoepitheliomatous hyperplasia of squamous epithelium, plasma cell infiltration and are positive for HSV 1 and/or HSV 2. Herpes simplex vegetans often responds poorly to treatment in immunocom-promised patients.

Discoid Lupus Erythematosus (DLE) in a Spitz Dog

A 3-year-old, female Spitz, was presented due to lack of response to therapies with a 6-month history of skin lesions characterized by diffuse erythema and scaling on the dorsal trunk. Physical examination revealed the dog was active and healthy. Skin culture isolated no fungus. Histological examination of skin biopsy specimens revealed interface dermatitis with hydropic degeneration of the basal layers, predominant plasmacytic perivascular accumulation in the dermis, and intensive plasma cell-rich interface mural folliculitis. Moderate CD3-positive lymphocytes infiltrated the superficial dermis. This report may provide unique information of canine discoid lupus erythematosus in an unusual breed with atypical cutaneous lesions.

Liver transplant recipient with concomitant cutaneous and visceral leishmaniasis

Diagnosis of leishmaniasis in immunosuppressed patients may be a serious challenge for physicians because of the major clinical and laboratory differences with immunocompetent patients. In immunosuppressed patients, the disease is characterized usually by disseminated visceral involvement, atypical cutaneous lesions and persistent negativity of diagnostic tests. Here, we report an eight-yr-old liver transplant recipient with concomitant cutaneous and visceral leishmaniasis in whom the cutaneous lesion led to the diagnosis of systemic involvement.