Nodular Cutaneous Lesions Research Articles

Prurigo: diagnosis and management.

Prurigo is a condition of nodular cutaneous lesions that itch (pruire) intensely. Although the acute form can be caused by insect stings, most of the subacute and chronic forms appear to be idiopathic. Toxic agents deposited in the skin by exogenous factors such as parasites, bacteria, or topically or orally administered drugs can induce itch. In susceptible individuals, physical mechanisms such as UV light can induce changes in epidermal innervation that result both in itch generally and in prurigo lesions. Prurigo is sometimes associated with atopy, pregnancy, internal diseases, malabsorption, or malignancy. Some forms of prurigo may be secondary to scratching. Emotional factors can also influence the perception of itch and induce prurigo by provoking scratching. These are the various specialized forms of prurigo, and there are certain others, such as prurigo pigmentosa, that have some ethnic preference. Topical treatments by corticosteroids, coal tar, bath photochemotherapy, UVB, cryotherapy, or capsaicin, as well as systemic regimens involving use of psoralen + UVA (PUVA), erythromycin, arotinoid acid, cyclosporine, chloroquine, dapsone, minocycline, naltrexone, azathioprine or thalidomide are used for the treatment of this condition. Psychotherapeutic agents to treat problems of mood that deteriorate prurigo are also prescribed. Combined sequential treatments for generalized, therapy-resistant cases need to be tailored to the exacerbations that occur and to provide maintenance treatment in order to enable the patient to withstand the intolerable itch.

Clinical Features and Outcome of Eleven Patients with Disseminated Bacille Calmette-Guérin (BCG) Infection

Disseminated BCG infection is a very rare complication of BCG vaccination. This study presents 11 patients with such complication. The underlying disease in eight of the 11 patients was primary imm...

Unusual cutaneous lesions associated with chronic myelomonocytic leukaemia

A 69-year-old man presented with unusual nodular cutaneous lesions of 3 years duration predominantly involving the chest, upper back and scalp. Histopathological changes in biopsy specimens from affected skin resembled those seen with granuloma annulare even though there was a lack of epithelioid cells. Based on the sluggish course of the condition, leukocytosis with monocytosis in peripheral blood and the findings on electron microscopic examination of peripheral blood cells, he was diagnosed as having chronic myelomonocytic leukaemia (CMMoL). At lower magnification under the electron microscope, the nodular skin lesions showed pleomorphic cell features with monocytes and histiocytic cells of abnormal appearance. The skin lesions were thus considered to be an unusual type of leukaemia cutis.

The Evolution of Hodgkin's Disease and Necrobiotic Xanthogranuloma Syndrome

We describe a woman in whom hypogammaglobulinemia and severe granulomatous cutaneous lesions had developed during childhood; subsequently, Hodgkin's disease and necrobiotic xanthogranuloma were diagnosed. This case illustrates an apparent association with disease activity and raises the question of a direct relationship of necrobiotic xanthogranuloma with lymphoproliferative disease.

Mycobacterium chelonae

M. chelonae is emerging as an important pathogen in the settings of immunosuppression and antecedent trauma. It characteristically produces nodular cutaneous lesions, which are preferentially located on the extremities. Surgical biopsy of a lesion is the diagnostic procedure of choice; the specimen should be incubated at 28 to 32°C to ensure optimal growth. Treatment is difficult and the infection usually follows a chronic, relapsing course. Erythromycin in combination with either amikacin or tobramycin is appropriate empiric therapy, but specific susceptibility testing should be performed. Accurate subspeciation of clinical isolates is also important, because antibiotic sussceptibility varies predictably between subspecies.

Nodular Lesions in Disseminated Mycobacterium fortuitum Infection

To the Editor.— Mycobacterium fortuitum , a rapidly growing mycobacterium of Ruyon's group IV, was reported to be a pathogenic organism by da Costa in 1938. 1 The most frequent human diseases caused by M fortuitum are cutaneous or soft-tissue infections, usually preceded by injections, trauma, or surgery. Other possibilities are pulmonary infections in previously damaged lungs, corneal infections, and bacillemia from contaminated prostheses or catheters. 2-6 We report a case of disseminated M fortuitum infection with multiple cutaneous nodular lesions. Report of a Case.— A 77-year-old woman was admitted to La Paz Hospital (Madrid) because of nodular cutaneous lesions on the abdomen and extremities, fever, asthenia, Fig 1.—Multiple nodular inflammatory lesions on thigh. Fig 2.—Granulomatous and abscessed inflammatory infiltration on the subcutaneous tissue (hematoxylin-eosin, ×10). anorexia, and a 10-kg weight loss in the last two months. Three years before, a pacemaker was implanted because of acute heart block. Shortly after

Cutaneous histiocytosis syndromes.

Cutaneous histiocytosis may take two principal forms. It is either a benign proliferative process or a relentless, progressive process with a poor prognosis. In histiocytic medullary reticulosis, histiocytes demonstrate nuclear atypia and the outcome is uniformly fatal. Benign cephalic histiocytosis X causes lesions similar to those of histiocytosis X, but Langerhans' cells are absent. In congenital self-healing histiocytosis X, the Letterer-Siwe-like cutaneous infiltrate contains Langerhans' cells, but the lesions heal spontaneously without treatment. The nodular cutaneous lesions of juvenile xanthogranuloma appear in infancy and resolve without treatment; however, the higher percentage (10%) of associated ocular lesions may lead to glaucoma and blindness. In histiocytosis X, the cutaneous lesions show a marked proliferation of Langerhans' cells, with prognosis dependent on the patient's age and the extent of organ dysfunction. Patients who survive the acute form of the disease may develop diabetes insipidus, growth retardation, pulmonary fibrosis, and biliary cirrhosis. A subtle immunologic defect has been identified in patients with histiocytosis X, yet the pathogenesis of the disease is still speculative. Familial disease occurring in early infancy should be differentiated from complete or partial immunodeficiency syndromes. Guidelines for evaluating patients with cutaneous histiocytosis are reviewed.

Successful immune reconstitution in severe combined immunodeficiency despite Epstein-Barr virus and cytomegalovirus infections

Cytomegalovirus (CMV) and Epstein-Barr virus (EBV), frequently found in the acquired immune deficiency syndrome (AIDS), have been suspected of contributing to the latter immunodeficiency. The ability of normal HLA-identical sibling bone marrow to reconstitute an 8-month-old infant with severe combined immunodeficiency infected with these two viral agents is of interest. After presentation with severe mucocutaneous candidiasis, cavitary pulmonary disease, nodular cutaneous lesions, and hepatic abscesses containing acid-fast organisms, immunologic studies revealed lymphopenia. 1–3% T cells, and no lymphocyte responses to mitogens. Prior to transplantation, the infant's blood B lymphocytes grew spontaneously in culture, suggesting they were infected with EBV. Indeed, an appropriate antibody response to EBV was detected at 2 months post-transplantation. At 3 weeks postgrafting, neutropenia and cholestatic jaundice developed without other signs of graft versus host disease. Liver biopsy demonstrated CMV but no EBV by DNA hybridization. There was evidence of T- and B-cell function by 2 weeks postgrafting, including vigorous in vivo and in vitro responses to candida. Although the blood lymphocyte T4:T8 ratio was inverted at 2 weeks, it reverted to normal by 6 weeks post-transplantation. All clinical disease resolved by 8 months and karotyping revealed all T and B lymphocytes to be XX. Thus, despite infections with both CMV and EBV, complete immunologic reconstitution was achieved in this, the most severe of all genetically determined immunodeficiency conditions, arguing against these viruses having a major role in the failure of bone marrow transplantation in AIDS.

Enzyme variation and difference in infectivity within a single strain of Leishmania mexicana mexicana

Grimaldi G. Jr., Momen H., Soares M. J. and Moriearty P. L. 1982. Enzyme variation and difference in infectivity within a single strain of Leishmania mexicana mexicana. International Journal for Parasitology 12: 185–189. Samples prepared from different promastigote and amastigote forms of a single strain of Leishmania mexicana mexicana were examined by isoelectrofocusing technique to investigate if the GP1 banding patterns were affected by intrastrain variation and to evaluate the relationship between intrinsic parasite factors and infective capacity. Promastigotes recently cultured in vitro produced more bands than samples maintained for a long period in vitro. There was also a difference in banding patterns between amastigotes and promastigotes while amastigotes isolated from skin and viscera of the same animal showed different patterns. These findings suggest that adaptative modifications in enzymes may occur with changes in environment. L. m. mexicana usually produced progressive nodular cutaneous lesions in mice but animals infected with either amastigotes or promastigotes recently cultured in vitro developed significantly more nodular lesions than those infected with promastigotes maintained for a long period in vitro. These results show that enzyme variant profiles may contribute in elucidating parasite factors associated with such characteristics as virulence and tissue tropism in Leishmania.

Experimental Studies with Torula from a Knee Infection in Man 1

Summary Torula histolytica recovered from a human case in which there was a local involvement of the knee joint together with the subsequent occurrence of lesions in the region of the nipples has been studied in culture and by inoculation into certain laboratory animals. This strain is similar to other strains recovered from cases showing brain and spinal cord lesions, both in regards to its morphologic characteristics and its fermentation reactions. Rats and mice became infected easily upon intraperitoneal inoculation but three guinea pigs and three rabbits inoculated resisted infection. Two monkeys inoculated intracardially developed unusually small nodular cutaneous lesions on the face, eyelids and ears from which torulae were recovered. One of the monkeys developed a generalized torulosis involving the brain and spinal cord while the second monkey recovered in four months. Other monkeys inoculated by the same route with strains of torula obtained from human nervous tissue developed lesions of the brain and cord but failed to show cutaneous lesions. These observations raise certain questions with reference to tissue selectivity of different strains of torula and also with reference to spontaneous recovery from torula infection.

SARCOIDS AND RELATED LESIONS

With Boeck's 1 description of the sarcoids, a morphologic entity was admittedly established. It soon became apparent, however, that his conception of the eruption was not sufficiently inclusive, as evidenced by the acceptance of a subcutaneous type referred to as the Darier-Roussy type. Later, Darier 2 classified sarcoids into four types. As experience with these nodular lesions grew it became apparent that a sharp dividing line could not be drawn, except that Darier's type 4 has been rather definitely eliminated from this group since it probably is a lymphoblastomatous disease. Both Boeck and Darier believed the sarcoids to be tuberculous in origin. Further study contributed much evidence to this belief, but it also indicated that other nodular cutaneous lesions, for example, lupus pernio 3 (not the chilblain lupus of Hutchinson) and erythema induratum, were closely related to the sarcoids, so much so that Lewandowsky 4 and Kyrle 5 have coined