Atypical Cutaneous Manifestations Research Articles

An Atypical Cutaneous and Histopathological Manifestation of Secondary Syphilis in an HIV-Positive Male: A Case Report

We present an atypical case of secondary syphilis concomitant with condyloma lata in an HIV-positive male. The patient presented with lesions on his lateral neck, soles, and palms. Spirochetes were examined on the biopsy of the palm, consistent with secondary syphilis, but not on the biopsy from the neck. The lesion on the neck was diagnosed as an evolving secondary syphilis lesion due to the extent of the lymphoplasmacytic infiltration, presence of acanthosis and epidermal hyperplasia, the accompanying diagnosis of secondary syphilis on the palm, the patient’s history of HIV, and the related diagnosis of condyloma lata on the dorsal shaft of the penis. Following this diagnosis, the patient was referred to an infectious disease specialist who treated him with a single intramuscular injection of 2.4 million units of benzathine penicillin, per CDC guidelines. This case highlights the importance of clinicians taking into consideration a variety of factors when diagnosing and treating cutaneous disorders with a broad-spectrum differential diagnosis, particularly in at-risk individuals.

Manifestações cutâneas em seis crianças pelo CHIKV: uma série de casos

Objectives: To describe a case series of children diagnosed with Chikungunya virus (CHIKV) infection with atypical dermatologic manifestations, in order to broaden the picture of possibilities for differential diagnoses in cases of similar clinical presentations. Methods: This is a series of cases in which were included all patients aged between zero and 18 years and who, between January, 2018 and November, 2020, were admitted to the emergency department of a pediatric public hospital, presenting atypical cutaneous manifestations associated with a clinicalepidemiological or laboratory diagnosis of CHIKV. Results: A total of six patients were screened from a cohort of 432 patients. Of these, four were female and five were under one year of age. The most reported manifestations were fever of sudden onset, besides exanthema and bullous skin lesions, mainly affecting the limbs. There was hospitalization of five of patients, without deaths. Conclusion: Cutaneous presentations are of different magnitude according to the age range affected by CHIKV, especially for children under one year of age, affecting mainly extremity areas of the body surface. It is therefore worth noting that pediatric patients deserve greater attention and early care, in order to reduce complications from the infection and thus also the morbidity of the affected population

Adult-Onset Still’s Disease with an Atypical Cutaneous Manifestation

Adult-onset Still’s disease (AOSD) is a rare systemic inflammatory disorder, characterized by daily fevers, arthralgias, and rash without evidence of infection. Recently there has been a growing number of cases reported with atypical cutaneous manifestations. We present a 37-year-old type VI Fitzpatrick skin type female who was seen in the hospital for a pruritic rash on her chest, back, and legs. Skin examination was significant for hyperpigmented papules coalescing into plaques on the chest, and hyperpigmented linear patches and excoriated plaques on the back and legs. Punch biopsy showed acanthosis and numerous apoptotic keratinocytes in the upper layers of the epidermis, which was characteristic of AOSD. As of recently, there is a growing body of evidence describing an atypical eruption of persistent, pruritic papules and plaques with typical histologic findings of AOSD. Further, these atypical features may be associated with more severe symptoms, higher incidence of macrophage activation syndrome, and possible delayed malignancy. Due to the scarcity of atypical cutaneous manifestations reported in the literature, these eruptions have not been included in the diagnostic criteria and can therefore be overlooked and misdiagnosed. Prompt recognition of these atypical eruptions is imperative to prevent a worsening prognosis and serious adverse effects.

P094 Atypical cutaneous manifestations of sporotrichosis in Brazil

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PMObjectivesInform the general practitioner of the possibilities of cutaneous manifestations secondary to sporotrichosis unrelated to the classic finding of contiguous lymphocutaneous ulcers.MethodsThis is a single-center, cross-sectional, retrospective study with patients evaluated and seen from June 2018 to April 2022 at the Mycology Outpatient Clinic of Hospital Universitário Oswaldo Cruz, University of Pernambuco.All patients were evaluated by the same infectious disease physician throughout the course, from diagnosis to outpatient discharge.Scrapings and cultures were collected by the institution's specialized Mycology team. Biopsies were sent to the University Pathology Service (CIAP).ResultsDuring the 4-year period, 231 patients started their treatment for sporotrichosis following clinical, laboratory, and histopathological criteria. Of these, 35 had atypical skin manifestations (15.15%).Of the 35 cases, most had erythema nodosum (22/35 - 63%), followed by simple cutaneous (6/35 - 17%), polymorphous erythema (5/35 - 14%), and cutaneous fistula and lymphangitis with one case each (Fig. 1).Both erythema nodosum and erythema nodosum showed a good response to corticosteroid therapy (standard with 20 mg prednisone for 5 days). In non-responsive cases, we increased the dose to 40 mg with a good response.Simple cutaneous lesions were infiltrating still in the process of ulceration without presenting involvement of the contiguous lymph node chain. The face, abdomen, chest, and limbs were the affected sites.One of the cases was a dental abscess with a fistula to the face. Upon biopsy of the lesion on the right hemiface, spores suggestive of sporotrichosis were found. When examining the patient, we observed the compromised right upper malar, which was surgically removed with drainage of the gingiva and the presence of Sporotrix in both the tooth and the gingiva.And, finally, a case of lymphangitis with improvement after specific treatment with itraconazole whose diagnosis was made by biopsy with Sporotrix findings in lymphatic vessels.As most patients had a late diagnosis due to the difficulty in carrying out the specific investigation of the agent by a non-specialized team, the diagnosis by scraping and culture was compromised by early treatment with antifungals, especially itraconazole. It is very common in the Northeast of Brazil that the association of sick cats with typical lesions of sporotrichosis is the main epidemiological factor since our case series for infections caused by soil manipulation is low. Therefore, 37% (13/35) had a clinical-epidemiological diagnosis of sporotrichosis, with an excellent clinical response to itraconazole (Fig. 2). Our standard dose is 200 mg/day after lunch, as a fatty diet interferes with improved medication absorption. All patients were instructed not to use medications with known interactions, especially proton pump inhibitors and alcohol use.ConclusionLymphocutaneous sporotrichosis is the most common manifestation, but there is a need for care teams working in primary and secondary care to identify atypical skin lesions and expand the investigation into the possibility of fungal infections. The epidemiology of the neighborhood associated with the presence and contact with sick cats with ulcerative lesions must be considered and taken into account.

The Great Imitator: Atypical Cutaneous Manifestations of Primary Syphilitic Chancre

The Great Imitator: Atypical Cutaneous Manifestations of Primary Syphilitic Chancre

Atypical hand foot mouth disease presenting as vesiculobullous lesion

Hand, food, and mouth disease (HFMD) is a highly contagious disease caused by enteroviruses affecting young children under 5 years. Among enteroviruses (EVs), the main pathogens of HFMD are coxsackievirus A16 (CV-A16) and EV-A71 (EV-71).1 The clinical features include a prodromal phase which has low-grade fever, malaise and sore throat. This initial phase is usually followed by enanthem and erythematous papular skin lesions, predominantly affecting palms and soles. The dorsal surface of hands, feet, and perioral skin are rarely affected. Atypical HFMD presents as a widely distributed rash with varying morphology that makes clinical diagnosis and treatment challenging.2 Our objective is to present atypical cutaneous manifestations of HFMD caused by CA6.

Arthritis-Dermatitis Syndrome: a Case of Disseminated Gonococcal Infection with Petechial Skin Rash

A previously healthy 36-year-old woman was admitted to the hospital with vaginal discharge, bilateral ankle pain, and a lower extremity skin rash, all of which developed after unprotected vaginal intercourse with a new male partner. On examination, there was a petechial and purpuric rash involving the lower extremities and bilateral tenosynovitis of the ankle dorsiflexor tendons. Urine NAAT was positive for Neisseria gonorrhea, confirming disseminated gonococcal infection (DGI). The patient was initially treated with oral azithromycin and intravenous ceftriaxone, but as a result of psychosocial circumstances, she was prematurely discharged on an oral cephalosporin agent. She represented with treatment-failure DGI and was treated with a 7-day course of intramuscular ceftriaxone. Repeat urine NAAT was negative for gonorrhea and the patient remained asymptomatic. This case features an atypical cutaneous manifestation of DGI, characterized by a painless petechial and purpuric skin rash rather than the tender papulo-pustular lesions that are typically seen. Additionally, it highlights the importance of DGI treatment with a 7-day parenteral cephalosporin therapy when antibiotic susceptibility is not available.

Atypical cutaneous manifestations in lupus erythematosus: A report of three cases

Atypical cutaneous manifestations in lupus erythematosus: A report of three cases

Extensive Palisaded Neutrophilic Granulomatous Dermatitis with Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a multi-system disease with a myriad of mucocutaneous and systemic findings. One of the atypical cutaneous manifestations is palisaded neutrophilic granulomatous dermatitis (PNGD). This uncommon condition presents as tender or asymptomatic, flesh-colored, red to violaceous subcutaneous nodules. The diagnosis may be suspected clinically but is confirmed by biopsy. The impact of the disease may be the direct result of pain, psychosocial, cosmetic concerns, or be the initial presentation of an underlying systemic disease. We present a patient with known SLE who developed PNGD. We also review similar clinical and microscopic disease entities with a summative comparison of neutrophilic dermatoses in patients with autoimmune connective tissue diseases.

Disseminated cutaneous gout: a rare manifestation of a common disease

Disseminated cutaneous gout is a rare atypical cutaneous manifestation of gout in which widespread dermal and subcutaneous tophi develop at extra-articular body sites. Given the lack of joint involvement that is typically a feature in tophaceous gout, the diagnosis may not be initially suspected. We present the case of a 50-year-old Hispanic man with poorly controlled gout who was evaluated for several years of firm papulonodules over the trunk and upper and lower extremities, sparing the joints; histopathology confirmed, the diagnosis of disseminated cutaneous gout. Per our literature review, disseminated cutaneous gout presents with polymorphous papules and nodules that can mimic other, more common cutaneous diseases. There is a preponderance of cases in males, Asians, and patients with longstanding gout. The lower extremities are involved in nearly all reports. Uric acid-lowering therapy with allopurinol has been reported to decrease the size and number of lesions in a minority of treated patients.

Sífilis Maligna Precoce em Paciente Imunodeprimido

A sífilis maligna precoce, também chamada sífilis nódulo-ulcerativa, foi descrita inicialmente por Bazin em 1859, relacionada a graus variáveis de imunodeficiência, em especial, a síndrome da imunodeficiência adquirida (SIDA) humana causada pelo vírus da imunodeficiência humana (VIH). É uma variante agressiva e generalizada da sífilis secundária com pródromos de febre, cefaleia, mialgia e artralgia, seguida de erupções papulopustulosas e necróticas. Devido à sua raridade e apresentação clínica pleomórfica, esse quadro é geralmente subdiagnosticado, o que pode levar, por vezes, ao desfecho fatal. Relatamos um caso de sífilis maligna em um paciente do sexo masculino, 40 anos, imunodeprimido por infecção pelo VIH, com manifestação cutânea atípica exuberante e sintomas constitucionais, o que se tem tornado raro devido à introdução de terapêutica antirretroviral altamente eficaz.

Intrauterine herpes simplex virus type one infection presenting with skin erosions and ulcers: Masking as neonatal sepsis

Neonatal infection with herpes simplex virus (HSV) either type 1 or type 2 can be acquired in utero, intrapartum, and postnatally. We report a case of intrauterine HSV type 1 infection with atypical cutaneous manifestations, misdiagnosed initially as neonatal sepsis. A high index of suspicion with diverse cutaneous manifestations kept in mind is necessary to diagnose infants with intrauterine HSV infection.

The Great Imitator: Atypical Cutaneous Manifestations of Primary Syphilitic Chancre.

Objective To analyze the reasons of misdiagnosis of primary syphilitic chancre and strengthen the understanding of atypical features of this disease. Methods A case series of twenty-seven challenging primary syphilis patients who were not immediately recognized as chancre was included in our study. The clinical data including the patients' age, sex, skin lesions, HIV status, syphilis serologic test results, treatment, and follow-up results were collected. Hematoxylin-eosin and immunohistochemistry staining of skin biopsy sections were reviewed. Results Four female cases with extragenital chancres presenting as erythema or erosive skin lesions on the nipple were misdiagnosed as Paget's disease or eczema. The disorder of missed or misdiagnosed male cases manifested as syphilitic balanitis or multiple chancres on the penis root and adjacent pubis rather than coronal sulcus or frenum. Patients with nonreactive nontreponemal tests at initial presentation were also easily missed or misdiagnosed. Conclusion Primary syphilis presenting as multiple lesions rather than a single chancre, at atypical locations, or with a nonreactive nontreponemal test result, tends to be missed or misdiagnosed.

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.

Adult-onset Still's disease with atypical cutaneous manifestations

The diagnosis of adult-onset Still's disease (AOSD) can be very difficult. There are no specific tests available, and diagnosis is usually based on a symptom complex and the well-described typical evanescent rash seen in the majority of patients. However, in recent years, other atypical cutaneous manifestations of AOSD have been reported. These atypical skin eruptions often present in addition to the typical evanescent rash but may also be the only skin manifestation, resulting in delayed diagnosis because of under-recognition.In this study, we present 3 new cases of AOSD with atypical cutaneous manifestations diagnosed during a 30-year period in our department and review 78 additional cases previously reported (PubMed 1990–2016). These 81 patients form the basis of the present analysis.The overall prevalence of atypical cutaneous manifestations in our AOSD population was 14%. These manifestations may appear at any time over the course of the disease, and usually occur in patients who have persistent and severe disease, with a considerable frequency of clinical complications (23%), including serositis, myopericarditis, lung involvement, abdominal pain, neurologic involvement, and reactive hemophagocytic syndrome.The most representative and frequent lesion among the nonclassical skin rashes is the development of persistent pruritic papules and/or plaques. Interestingly, these lesions show a distinctive histological pattern. Other, less frequently observed lesions include urticaria and urticaria-like eruptions, generalized or widespread non-pruritic persistent erythema, vesiculopustular eruptions, a widespread peau d’orange appearance of the skin, and edema of the eyelids mimicking dermatomyositis without any accompanying skin lesion.The great majority of these patients required medium or high doses of glucocorticoids (including intravenous methylprednisolone pulse therapy in some cases) and, in nearly 40%, a more potent or maintenance immunotherapy with immunosuppressant drugs and/or biologic agents (mainly anakinra or tocilizumab) to control or manage symptoms because of a polycyclic or chronic course. The development of atypical cutaneous manifestations seems to be associated with a potentially worse prognosis, with a mortality rate reaching 8% primarily because of infectious complications related to immunosuppressive therapy.In conclusion, the appearance of atypical cutaneous manifestations is not uncommon in AOSD. Recognition of this clinical variant is crucial for the early diagnosis of AOSD, as it might imply persistent disease activity and the need for more aggressive treatment.

Stenotrophomonas maltophila cellulitis in an immunocompromised patient presenting with purpura, diagnosed on skin biopsy

Stenotrophomas maltophilia is an opportunistic Gram-negative bacillus and an important cause of nosocomial infections, particularly in immunosuppressed individuals. Although infections with this organism are most often in the form of pneumonia, bacteremia and endocarditis, awareness of the impact of S. maltophilia skin infections has been increasing. Here we describe a case of S. maltophilia cellulitis in a 65-year-old man with severe neutropenia and purpuric skin lesions to highlight the critical histopathological findings and correlate them with the clinical manifestations of the skin infection with this organism. Because identification of S. maltophilia can be challenging and infections are difficult to manage, this case illustrates essential considerations regarding the multifaceted histopathological, dermatological, clinical and microbiological aspects of the diagnosis and treatment of S. maltophilia cellulitis in a severely immunocompromised patient. Cognizance of the increasing incidence of nosocomial infections with uncommon microorganisms such as S. maltophilia is necessary when presented with atypical cutaneous manifestations, particularly in immunocompromised patients.

Atypical Cutaneous Manifestations in Syphilis

Although the diversity of the clinical manifestations of syphilis is well-known, atypical presentations can also occur. Such atypical presentations are associated with a high risk of transmission as a result of diagnostic confusion and treatment delays owing to the disease's ability to mimic other common skin diseases, deviate from classic clinical presentations, and adopt unique forms. Cases of atypical syphilis have been described most frequently in patients with concomitant human immunodeficiency virus (HIV) infection. Because the incidence of syphilis has been growing over recent years —particularly in patients with HIV co-infection—dermatologists need to be familiar with the less well-known clinical presentations of this venereal disease.

Atypical Cutaneous Manifestations in Adult Onset Still's Disease.

Adult Onset Still's Disease (AOSD), an adult variant of systemic onset juvenile idiopathic arthritis, is a rare systemic inflammatory disorder of unknown aetiology. The rarity of this disease is associated with low index of suspicion and delayed diagnosis in patients suffering from it and in the presence of atypical features the diagnosis can be further challenging. This is a case report on a 24-year-old woman, who was a diagnostic dilemma for 2 years due to the nonspecific symptoms of recurrent fever, generalized maculopapular persistent pruritic and tender rash, and polyarthralgia. She was initially diagnosed as leukocytoclastic vasculitis on a skin biopsy and was managed by a dermatologist with various medications including NSAIDs, hydroxychloroquine, dapsone, colchicine, cyclosporine, and high doses of oral steroids with minimal response. Subsequently, she has had multiple admissions with similar symptoms with raised inflammatory markers and negative septic workup. On one occasion, her iron study revealed hyperferritinaemia which led to the suspicion of AOSD. Once the rheumatic fever and infectious, malignant, autoimmune, and lymphoproliferative disorders were excluded, she was diagnosed as probable AOSD and managed successfully with IL-1 (interleukin-1) receptor antagonist, Anakinra, with remarkable and lasting response both clinically and biochemically.

Typical evanescent and atypical persistent polymorphic cutaneous rash in an adult Brazilian with Still's disease: a case report and review of the literature.

Adult onset Still’s disease (AOSD) is a systemic auto-inflammatory condition of unknown etiology, characterized by high fever, an evanescent, salmon-pink maculopapular skin rash, arthralgia or arthritis and leukocytosis. AOSD can also present with atypical cutaneous manifestations, such as persistent pruritic coalescent papules or plaques and linear lesions that have highly distinctive pathological features and are usually associated with severe disease. Herein, we present a 31-year-old Brazilian man with both typical Still’s rash and atypical persistent polymorphic cutaneous manifestations associated with severe systemic inflammatory response syndrome. Eosinophils that are consistently lacking in the AOSD-associated skin lesions were evident in the skin biopsy of the persistent atypical cutaneous manifestations and were either drug-related or AOSD-associated.

Hand-foot-and-mouth disease: a new look at a classic viral rash.

Hand-foot-and-mouth disease (HFMD) is a common cause of viral rash in children with classic skin findings which are easily recognized by pediatricians. Recently, several atypical cutaneous manifestations of HFMD have been described. Awareness of these patterns may lead providers to appropriate diagnosis and management. This review also highlights the epidemiological patterns of more virulent strains and emerging research in disease prevention. Classic HFMD presents with tender lesions on the hands, feet, and oral mucosa. Atypical skin findings in HFMD may be seen in children with atopic dermatitis. These include 'eczema coxsackium', in which eczematous skin is superinfected with coxsackie virus, resembling herpes infection. Nail changes, such as shedding, may follow HFMD after a latency period. Enterovirus 71 is responsible for epidemic outbreaks of HFMD in Asia, with systemic manifestations and occasionally neurological sequelae. Research is underway to develop a vaccine which could curb epidemics, but for the present, supportive care and hygiene measures are the standard of care. Atypical manifestations of HFMD in children with atopic dermatitis may mimic herpetic superinfection. In a child presenting with nail changes, consider antecedent HFMD in the differential diagnosis. The mainstay of treatment for HMFD remains supportive care.