Cutaneous Nodules Research Articles

Lumpy skin disease: a systematic review of mode of transmission, risk of emergence, and risk entry pathways.

Lumpy skin disease (LSD), a viral disease of cattle, can be acute, subacute, or inactive. It is distinguished by fever and the abrupt emergence of firm, confined cutaneous nodules that usually necrotize. Similar lesions may occur in the skeletal muscles and the mucosae of the digestive and respiratory tracts. It is an enzootic, rapidly explorative, and sometimes fatal infection, characterized by multiple raised nodules on the skin of infected animals. LSDV has a large genome, it is employed as a vaccine carrier, generating a new complex with other viral genes by homologous recombination. This review summarizes our current knowledge of lumpy skin disease (LSD), its impact on animal health, host-pathogen interaction, etiology, signs or symptoms, prevention, and treatment strategies.

Carcinoma buccal mucosa with cutaneous metastasis: An unusual presentation

Head-and-neck cancer is a common cancer in India. Oral cavity cancer accounts for 50% of all head and neck sites. The most common sites of distant metastasis are the lung, liver, and bone. The incidence of cutaneous metastasis is a very rare site. We report a case of early-stage carcinoma buccal mucosa post-surgery and adjuvant radiotherapy developed skin metastasis shortly after completion of treatment. A 37-year-old female non-smoker, non-alcoholic diagnosed with early-stage carcinoma right buccal mucosa cT1N0M0. She underwent surgery of wide local excision with marginal mandibulectomy and extended supra-omohyoid neck dissection. In post-surgery, the histopathological report was moderately differentiated squamous cell carcinoma, pT2N1Mx. She completed her adjuvant radiotherapy 59.4Gy/33 fractions with six cycles of concurrent chemotherapy cisplatin 40 mg/m2. She developed difficulty in swallowing, increased oral secretions, and thickening over right-sided scar marks shortly after 10 weeks of completion of treatment. Rapidly, she developed multiple cutaneous nodules over both sides of the entire face and neck. Dermal biopsy reveals metastatic squamous cell carcinoma. Skin metastasis from head-and-neck malignancy is an uncommon entity and in the early stage, it is very rare. Initially, it is difficult to diagnose as it looks like some disseminated bacterial or fungal infection but we should always keep in mind this entity as cancer can metastasize and present in any atypical forms.

Phaeohyphomycosis caused by Trematosphaeria grisea in an immunocompromised English springer spaniel

AbstractA 10‐year‐old, male, farm‐based springer spaniel that presented with subacute progressive left‐sided central vestibular signs was diagnosed with meningoencephalitis of unknown origin. The patient received prednisolone (2 mg/kg/day orally), ciclosporin (5 mg/kg orally twice a day) and a single infusion of cytarabine (200 mg/m2). Six weeks later, neurological signs had resolved, but multiple cutaneous nodules developed on the limbs, trunk and face. Lesions discharged a dark purulent material without tissue grains. A ‘filamentous fungus’ was isolated, but discarded without identification. Aspirates from nodules showed pigmented, septate fungal hyphae, and culture of aspirates yielded Trematosphaeria grisea. Itraconazole (5 mg/kg once a day) and gradual tapering of immunosuppressive drugs led to resolution of nodular lesions over 4 months without neurological relapse. A fungal granuloma developed transiently 8 months after starting itraconazole. Immunosuppressive drugs were stopped 15 months after introduction without neurological relapse. Itraconazole was withdrawn 8 weeks later, 5 months after last relapse of skin disease.

Scrotal calcinosis cutis an unrelated finding in benign prostatic hyperplasia patient, is treatment sine qua non? A case report

Calcinosis cutis is a reactive and nonmalignant lesion characterized by solitary or multiple cutaneous nodules that can affect different parts of the body including the scrotum among other structures. Treatment is often sought because of cosmesis, itching, or pain. Despite this, it remains unclear or unimaginable why patients will be reluctant to accept treatment in the face of disfigurement. Several reasons have been documented, but the fear of genital mutilation from open surgical intervention is an unfamiliar reason advanced by the index case for declining open surgical intervention. Its diagnosis requires careful clinical evaluation and is confirmed by lesional biopsy for histological confirmation. This is a case of a 50-year-old trader who presented to our facility with a 35-year history of multiple, painless scrotal nodules and difficulty in passing urine for six months’ duration. He was diagnosed with benign prostatic hyperplasia (BPH) with the indication for surgical therapy and idiopathic scrotal calcinosis cutis. He consented and had endoscopic therapy for benign prostatic hyperplasia (BPH) but was reluctant to open surgical intervention for idiopathic scrotal calcinosis cutis despite disfigurement because of the fear of genital mutilation. The current treatment options include follow-up observation, medications, cryotherapy, laser, and surgical excision, depending on the patient’s choice, availability, and surgical expertise. The surgical option is often favored and encouraged due to its associated reduced chances of recurrence. Therefore, it is pertinent to respect the patient’s opinion and should override other considerations in clinical practice. The lesson herein can assist other clinicians in avoiding justifiable medical litigations, hence, the need for this case report and a review of the literature.

Design of ANCHOR-RA: a multi-national cross-sectional study on screening for interstitial lung disease in patients with rheumatoid arthritis

BackgroundPatients with rheumatoid arthritis (RA) are at risk of developing interstitial lung disease (ILD), which is associated with high mortality. Screening tools based on risk factors are needed to decide which patients with RA should be screened for ILD using high-resolution computed tomography (HRCT). The ANCHOR-RA study is a multi-national cross-sectional study that will develop a multivariable model for prediction of RA-ILD, which can be used to inform screening for RA-ILD in clinical practice.MethodsInvestigators will enrol consecutive patients with RA who have ≥ 2 of the following risk factors for RA-ILD: male; current or previous smoker; age ≥ 60 years at RA diagnosis; high-positive rheumatoid factor and/or anti-cyclic citrullinated peptide (titre > 3 x upper limit of normal); presence or history of certain extra-articular manifestations of RA (vasculitis, Felty’s syndrome, secondary Sjögren’s syndrome, cutaneous rheumatoid nodules, serositis, and/or scleritis/uveitis); high RA disease activity in the prior 12 months. Patients previously identified as having ILD, or who have had a CT scan in the prior 2 years, will not be eligible. Participants will undergo an HRCT scan at their local site, which will be assessed centrally by two expert radiologists. Data will be collected prospectively on demographic and RA-related characteristics, patient-reported outcomes, comorbidities and pulmonary function. The primary outcomes will be the development of a probability score for RA-ILD, based on a multivariable model incorporating potential risk factors commonly assessed in clinical practice, and an estimate of the prevalence of RA-ILD in the study population. It is planned that 1200 participants will be enrolled at approximately 30 sites in the USA, UK, Germany, France, Italy, Spain.DiscussionData from the ANCHOR-RA study will add to the body of evidence to support recommendations for screening for RA-ILD to improve detection of this important complication of RA and enable early intervention.Trial registrationclinicaltrials.gov NCT05855109 (submission date: 3 May 2023).

Juvenile Xanthogranulomatosis in a Hemophilic Boy: Case Report

Juvenile Xanthogranulomatosis (JXG) is a condition, characterized by a proliferation of histiocytes, primarily observed in infants and young children. Cutaneous manifestations appear as yellow-orange-brown papules or nodules, typically localized on the face, neck, and upper chest. While most lesions regress spontaneously, some may require intervention for aesthetic, diagnostic, or hemorrhagic reasons. A rare case of disseminated JXG in a child with hemophilia has been reported. In this patient with severe hemophilia A, cutaneous nodules appeared, some associated with bleeding requiring appropriate management. Treatment included the administration of factor VIII to prevent bleeding during surgical procedures and secondary prophylaxis, to control recurrent bleeding. The outcome was favorable with the disappearance of the cutaneous lesions without sequelae, under regular surveillance for both medical conditions. This case highlights the rare association between juvenile xanthogranulomatosis (JXG) and hemophilia, a combination that has never been documented in the medical literature. This association only impacts the management of JXG when the cutaneous lesions bleed and their excision becomes necessary.

Posaconazole followed by combination itraconazole and terbinafine for treatment of disseminated histoplasmosis in a cat.

This is the first reported use of posaconazole for the treatment of feline disseminated histoplasmosis. Approximately 1-year-old female spayed domestic longhair cat. The cat presented to our institution with weight loss, lymphadenomegaly, hepatosplenomegaly, limb edema, abdominal fluid distension and ulcerated cutaneous nodules. The cat had been previously diagnosed with disseminated histoplasmosis at another institution approximately 6 months prior. Clinical signs had been refractory to treatment with fluconazole. Itraconazole had next been tried, and the cat's weight continued to decline, lesions failed to regress, and the cat formed abdominal fluid distension and marked pelvic limb edema. The cat was prescribed posaconazole along with prednisolone. The cat's demeanor, body weight, and lesions all markedly improved. Histoplasma antigen was undetectable in urine samples while the cat was receiving posaconazole. However, posaconazole blood levels paired with markedly elevated ALT suggested potential toxicity and the drug was discontinued. Upon cessation of posaconazole, the cat's lesions returned with cytologic evidence of intralesional Histoplasma yeast. Itraconazole combine with terbinafine was prescribed. At last follow-up, the cat was clinically well, off all anti-fungal medication, and without detectable Histoplasma antigen in the urine. Posaconazole therapy showed promise in this case. Had a safe and therapeutic dose been arrived at, we suspect that posaconazole would have cleared or maintained clinical remission of this cat's disease. This is the first report using posaconazole and the first successful report using combination itraconazole and terbinafine for the treatment of feline disseminated histoplasmosis. Generic drugs were used throughout this case report; the drug manufacturers are unknown to the authors.

Pediatric Orbital Juvenile Xanthogranuloma: A Case Series and Review of the Literature.

Juvenile xanthogranuloma (JXG) is a subtype of histiocytosis characterised histologically by foamy non-Langerhan cells with Touton giant cells. It typically manifests as a single self-limiting cutaneous nodule in the pediatric population. Orbital JXG is extremely rare, and its clinical course and management are not well understood or defined. Herein we present 3 cases of orbital JXG and provide a detailed literature review. Review of 3 cases with orbital JXG and literature review of all published cases. Three presented cases demonstrate the heterogeneous clinical course of orbital JXG. Although centred around the use of steroids, there is neither robust evidence nor consensus on its management. The wider JXG literature is currently concentrated around the classification of JXG with respect to histiocytosis, especially the exclusion of extracutaneous JXG as separate diseases. This separation is based on clinical, histopathological, and molecular findings. It is unclear where orbital JXG best fits in this emerging classification of JXG. Our review of the cases and literature on orbital JXG show that it may manifest with variable clinical course and its molecular pathogenic mechanism may be different to that of the cutaneous JXG.

Whole blood transcriptomics reveals the enrichment of neutrophil activation pathways during erythema nodosum leprosum reaction.

Patients with the multibacillary form of leprosy can develop reactional episodes of acute inflammation, known as erythema nodosum leprosum (ENL), which are characterized by the appearance of painful cutaneous nodules and systemic symptoms. Neutrophils have been recognized to play a role in the pathogenesis of ENL, and recent global transcriptomic analysis revealed neutrophil-related processes as a signature of ENL skin lesions. In this study, we expanded this analysis to the blood compartment, comparing whole blood transcriptomics of patients with non-reactional lepromatous leprosy at diagnosis (LL, n=7) and patients with ENL before administration of anti-reactional treatment (ENL, n=15). Furthermore, a follow-up study was performed with patients experiencing an ENL episode at the time of diagnosis and after 7 days of thalidomide treatment (THAL, n=10). Validation in an independent cohort (ENL=8; LL=7) was performed by RT-qPCR. An enrichment of neutrophil activation and degranulation-related genes was observed in the ENL group, with the gene for the neutrophil activation marker CD177 being the most enriched gene of ENL episode when compared to its expression in the LL group. A more pro-inflammatory transcriptome was also observed, with increased expression of genes related to innate immunity. Validation in an independent cohort indicated that S100A8 expression could discriminate ENL from LL. Supernatants of blood cells stimulated in vitro with Mycobacterium leprae sonicate showed higher levels of CD177 compared to the level of untreated cells, indicating that the leprosy bacillus can activate neutrophils expressing CD177. Of note, suggestive higher CD177 protein levels were found in the sera of patients with severe/moderate ENL episodes when compared with patients with mild episodes and LL patients, highlighting CD177 as a potential systemic marker of ENL severity that deserves future confirmation. Furthermore, a follow-up study was performed with patients at the time of ENL diagnosis and after 7 days of thalidomide treatment (THAL, n=10). Enrichment of neutrophil pathways was sustained in the transcriptomic profile of patients undergoing treatment; however, important immune targets that might be relevant to the effect of thalidomide at a systemic level, particularly NLRP6 and IL5RA, were revealed. In conclusion, our study reinforces the key role played by neutrophils in ENL pathogenesis and shed lights on potential diagnostic candidates and novel therapeutic targets that could benefit patients with leprosy.

Susceptibility of Mediterranean Buffalo (Bubalus bubalis) following Experimental Infection with Lumpy Skin Disease Virus.

Lumpy skin disease (LSD) is a viral disease of cattle and water buffalo characterized by cutaneous nodules, biphasic fever, and lymphadenitis. LSD is endemic in Africa and the Middle East but has spread to different Asian countries in recent years. The disease is well characterized in cattle while little is known about the disease in buffaloes in which no experimental studies have been conducted. Six buffaloes and two cattle were inoculated with an Albanian LSD virus (LSDV) field strain and clinically monitored for 42 days. Only two buffaloes showed fever, skin nodules, and lymphadenitis. All samples collected (blood, swabs, biopsies, and organs) were tested in real-time PCR and were negative. Between day 39 and day 42 after inoculation, anti-LSDV antibodies were detected in three buffaloes by ELISA, but all sera were negative by virus neutralization test (VNT). Cattle showed severe clinical signs, viremia, virus shedding proven by positive real-time PCR results, and seroconversion confirmed by both ELISA and VNT. Clinical findings suggest that susceptibility in buffaloes is limited compared to in cattle once experimentally infected with LSDV. Virological results support the hypothesis of buffalo resistance to LSD and its role as an accidental non-adapted host. This study highlights that the sensitivity of ELISA and VNT may differ between animal species and further studies are needed to investigate the epidemiological role of water buffalo.

MERKEL CELL CARCINOMA: A CASE REPORT

Merkel cell carcinoma is a rare but highly agressive skin tumor. MCC clinically represents as cutaneous or subcutaneous nodule, and in 30% of the cases loco-regional metastasis are already there in primary diagnosis. Pathogenesis is essentially due to excessive exposure to UV light. The confirmation diagnosis is based on histological and immunological features on the lesion. The treatment methods require a complete surgical excision and radiotherapy.

Differences in hidradenitis suppurativa patterns of cutaneous involvement between sexes: Insights from a cross-sectional study

Hidradenitis suppurativa is a chronic, inflammatory condition of the pilosebaceous unit in which patients manifest multiple, painful cutaneous nodules, abscesses and tunnels. These lesions are described to affect the intertriginous zones, however, the condition exhibits significant phenotypic variability. Such variability is influenced by the patients lifestyle, genetic predisposition and sex. In this cross-sectional study, we investigate sex differences in patterns of hidradenitis suppurativa skin involvement, specifically at site of first involvement and most bothersome cutaneous site of involvement.

Cutaneous metastasis in hypopharyngeal carcinoma: a case report.

Occurrence of cutaneous metastasis in hypopharyngeal carcinoma is an extremely rare event reported in the literature, with an incidence of only 0.8%-1.3%. Early diagnosis of cutaneous metastasis would have a positive impact on treatment response and disease prognosis with diagnosis mainly dependent on physical examination and radiological imaging (ultrasonography, computed tomography scan or PET-CT). Palliative care is, however, the mainstay of treatment for cutaneous metastasis. We report a middle-aged female patient, with known case of hypopharyngeal squamous cell carcinoma, who initially showed partial response to chemoradiotherapy but developed cutaneous nodules in the region of the right axilla and bilateral lateral chest wall posterior to the posterior axillary fold. Excision biopsy of one of these nodules showed metastatic squamous cell carcinoma. The patient was again referred to the Oncology Department of INMOL Hospital and her chemotherapy was planned for cutaneous metastasis. Being uncommon, the occurrence of cutaneous lesions in a patient with hypopharyngeal carcinoma should prompt detailed evaluation to rule out metastasis. Early detection will help in improving disease prognosis and median survival.

Clinical insights to address canine strongyloidosis in daily practice

Canine strongyloidosis by Strongyloides stercoralis is a parasitic disease emerging in Europe, which represents both a veterinary clinical issue and a public health challenge because of the zoonotic potential. The disease, not yet frequent in Europe, could induce severe clinical signs in dogs; thus, an early diagnosis and appropriate treatment are desirable. The aim of the present work is to retrospectively investigate the clinical and paraclinical findings in sick dogs naturally infected by S. stercoralis, with particular attention to ultrasound (US) changes at the gastrointestinal level. Twelve dogs were included in the study. The diagnosis was made by means of larval morphological identification on faecal samples and PCR. Most dogs presented with gastrointestinal signs; diarrhea and weight loss were the most common presenting complaint. Only one dog showed respiratory signs, associated to a parasitic cutaneous nodule. Hypoproteinaemia, anaemia, leucocytosis and an increase in alpha2-globulin fraction at serum protein electrophoresis were common (>50%) but not constant findings. The most reported US picture was a fluid-filled, distended, atonic small intestine mostly associated with altered wall layering, while the wall thickness commonly associated with chronic enteritis was only rarely reported. These changes, associated with other clinical and paraclinical alterations, could increase the suspicion of canine strongyloidosis and may direct clinicians to include strongyloidosis in the differential diagnosis of dogs with diarrhea. The histological examination at the intestinal level, available in five dogs, revealed the presence of parasites from the full-thickness biopsy, but not from the endoscopic biopsy. The critical points of diagnosis in clinical practice are also discussed.

O03 Sarcoidosis in a Boy with Severe Eczema on Dupilumab

Abstract Sarcoidosis, a systemic granulomatous disease of unknown aetiology, is rare in children. Presentation varies according to the extent and severity of organ involvement and is typically multisystem in older children. Drug induced sarcoidosis-like reaction (DISR) has recently been reported in patients taking Dupilumab. We describe a patient who developed sarcoidosis while on Dupilumab and question whether this was caused by the drug. A 14-year-old boy with severe eczema developed widespread cutaneous nodules and papules after 30 months on Dupilumab. Histology showed non-caseating granulomas. A raised serum angiotensin converting enzyme level, asymptomatic coarse interstitial markings on chest x-ray and small lung nodules on CT scan were also consistent with sarcoidosis. Dupilumab was stopped and hydroxychloroquine and methotrexate commenced. Joint and liver involvement developed 4 months later so systemic glucocorticoids were and the methotrexate was changed to mycophenolate mofetil. To our knowledge there have been 3 previous reports of DISR on Dupilumab. The clinical picture is almost indistinguishable from sarcoidosis. In this case continuing evolution of sarcoidosis 4 months after stopping Dupilumab argues against DISR. However, as Dupilumab becomes more widely used, it is important to be alert to the possibility of new adverse reactions.

Cutaneous nodule at the site of previous trauma in a 9-year-old male dog.

Cutaneous nodule at the site of previous trauma in a 9-year-old male dog.

Disseminated nocardiosis including cerebral nocardiosis caused by Nocardia farcinica: a case report

Background: As nocardiosis presents with nonspecific symptoms, its diagnosis is often difficult, resulting in high mortality. Here, we report a rare case of disseminated Nocardia farcinica infection that was successfully managed with a combination of antibiotic therapies. Case report: A 71-year-old man with idiopathic thrombocytopenia purpura presented with sudden-onset motor aphasia, motor weakness of the right limb, and fever. Brain magnetic resonance imaging revealed multiple scattered diffusion-restricted lesions. Multiple cutaneous and peritoneal nodules were also identified. We performed full-length 16S ribosomal ribonucleic acid (rRNA) sequencing and obtained basic local alignment search tool results against the National Center for Biotechnology Information 16S rRNA database, which showed the best match to be N. farcinica. After maintaining the antibiotics for approximately 56 days, the patient recovered full consciousness, and the motor weakness of the right limb improved.Conclusion: Timely diagnosis of disseminated or cerebral nocardiosis and treatment with appropriate antibiotics are crucial for a desirable clinical outcome.

Cutaneous Nodules - A Challenging Presenting Sign in Breast Neoplasm

Dr Mihalcea (Internal Medicine): A 77-year-old woman was admitted to the hospital because of dyspnea at rest, fatigability, unproductive cough (debuted 6 months prior to admission, with no improvement from common cough medication), and the onset, reportedly during the previous two months, of painful, erythematous, hard nodules distributed diffusely all over her body. She had a history of rheumatic heart disease, with severe mitralvalve stenosis, atrial fibrillation, and heart failure with reduced ejection fraction. Two months earlier she was admitted for a routine check-up at the Cardiology Ward of the hospital where she was being monitored for her cardiovascular pathology, and no nodules were reported.

Correlation between computed tomography and histological evaluation of nodal metastasis in dogs with mast cell tumours.

Early diagnosis of nodal metastasis has been shown to impact prognosis for dogs with mast cell tumours (MCT). The objective of this retrospective study was to determine the correlation between computed tomographic characteristics of lymph nodes and histologic nodal metastasis using the HN classification system, in dogs with cutaneous or subcutaneous MCT and regional lymph node(s) removal. Dogs that had removal of MCT and regional lymphadenectomy within 31 days of the initial staging computed tomography (CT) were enrolled. Subjective lymph node characteristics used included margination, loss of fat at hilus, shape of margin, perinodal fat pattern, increase in number of nodes, and pre- and post-contrast heterogeneity. Enhancement, heterogeneity, and short-long axis ratio were calculated. Seventy-one lymph nodes from 37 dogs were included. Generalised linear mixed model of assessment of lymph node was performed twice, with binary outcome [non-metastatic (HN0/1) versus metastatic (HN2/3)] and 4-point scales (HN0-HN3). After blind assessment of 7 characteristics described above, a final subjective interpretation of each lymph node as non-metastatic or metastatic was assigned. A significant correlation was found between final interpretation and prediction of metastasis. Higher HN classification was also significantly correlated with the increased number of nodes and pre- and post-contrast heterogeneity. No correlation was found in short-long axis ratio, calculated heterogeneity, or degree of enhancement. Sensitivity of CT was 35.7%, specificity was 96.6%, and accuracy was 60.5% for nodal metastasis. CT alone cannot be recommended for assessment of metastasis. The use of multiple computed tomographic characteristics may increase accuracy of nodal metastasis detection.

Ocular Metastasis from Breast Carcinoma: A Case Report

Background: Eye metastases are a rare event in cancer, patients with breast cancer being the most common primary site (28.5%–58.8%). Patients with ocular metastatic disease can present with a variable clinical picture. Most often presents as a cutaneous or subcutaneous nodule simulating a chalazion but with rapid growth and possible superficial ulceration. The definitive diagnosis is based on the anatomopathological analysis of the lesion. The treatment remains palliative and the prognosis remains poor. Objectives: To further define the histopathologic features of breast carcinoma conducive to orbital metastasis. Methods: We report a case of ocular metastasis in a 46-year-old woman presenting with right eye pain. She had been treated for ductal carcinoma breast cancer with lymph node and bone metastases 5 years ago; a mastectomy with lymph node dissection was performed. The patient consults us for unilateral eyelid swellings evolving for 4 months. On examination, we find well-limited rounded tissue formation in the right upper eyelid ulcerated in places. Oculomotricity was preserved and the rest of the examination was unremarkable. A biopsy of the lesion was carried. Results & Conclusions: Microscopic examination revealed a fibrofatty tissue seat of a tumoral proliferation made of spans and cords, of carcinomatous cells with moderate atypia showing some mitosis figures. The stroma is fibrous. Immunohistochemical studies showed positive immunoreactivity to pancytokeratin, estrogen receptor, progesterone receptor and HER-2, the results were in favor of a metastatic breast carcinoma. In summary, In the case of a metastatic orbital tumor, breast cancer should be considered as a possible source, especially in elderly women. Integrating the clinical information with histopathological findings is warranted.