Focal Microabscesses Research Articles

Evaluation of the response to treatment of psoriasis vulgaris with reflectance confocal microscopy

Reflectance confocal microscopy (RCM) is a noninvasive, objective imaging technique that provides in vivo, high-resolution skin imaging. We sought to assess epidermal and dermal changes associated with the psoriasis and its treatment with RCM before the treatment and at weeks 4 and 8 of the treatment. This is an investigator-blinded, internal-controlled, follow-up study. A total of 25 patients with plaque psoriasis were included in the study. The RCM evaluation criteria were defined on the basis of the histopathological diagnostic criteria for psoriasis. The clinical severity of the psoriasis was evaluated using the Psoriasis Area Severity Index (PASI). The RCM findings which were correlated with the PASI can be used to follow up the patient's response to treatment have been identified as follows: the acanthosis, the number of spongiotic sites, the number of regular/irregular honeycomb-like sites, the number of epidermal inflammatory cells, the number of focal microabscesses, the total epidermal thickness, the number of nonedge dermal papillae, the length of the papillary dermis, the number of dermal inflammatory cells, and the vascularization in the papillary dermis (P<0.05). This is the first study with a large group of patients to perform a noninvasive assessment with RCM of the response of psoriasis to different treatments: phototherapy, systemic and topical treatment. Micrometric and morphometric changes occurring in the psoriatic tissue during the 8-week treatment period were identified by in vivo RCM in a noninvasive manner. RCM is capable of monitoring of treatment response in psoriasis.

Tricuspid valve endocarditis complicated by septic pulmonary embolism in an intravenous drug user

Case reportA 32-year-old woman collapsed suddenly in the early hoursof the morning after visiting the toilet. Her partner made anemergency call immediately and started telephone-assistedcardiopulmonary resuscitation. Subsequent professionalresuscitation efforts were unsuccessful, and the woman waspronounced dead at the scene. She was known to be a long-term intravenous drug (IVD) user. A medicolegal autopsywas requested considering the woman’s young age and herspecific history of IVD abuse.Autopsy revealed the body of a poorly nourished Cau-casian woman, 162 cm in height and 55 kg in weight. Onexternal examination, there were prominent areas ofdepigmentation of the skin in the bilateral groin area, theanterior part of the right thigh, and the left cubital fossa.Fresh subcutaneous hemorrhages were seen on the anteriorpart of the right thigh with fresh puncture marks. Externalexamination also revealed multiple petechial hemorrhageson the right lower leg. Other external findings wereunremarkable.Dissection of the heart (weight, 280 g; dimensions13 9 10 9 4 cm) showed almost complete destruction ofthe anterior and septal cusps of the tricuspid valve (Fig. 1).The edges of the ulcerated cusps contained yellowishgranular vegetations. A smaller shaggy vegetation was alsopresent on the atrial aspect of the posterior cusp of thetricuspid valve, but the degree of destruction of the pos-terior cusp was not as severe as that of the anterior andseptal cusps. The leaflets of the tricuspid valve wereedematous and slightly coarse. A yellowish mass with aslightly granular surface was wedged into both branches ofthe pulmonary artery, causing complete obstruction(Fig. 2). The cardiac muscle was grossly normal. Therewas no septal defect. No pathological change was seen inthe coronary arteries.Further findings included septic changes of the spleen(weight, 460 g), congestion of the internal organs, and lungand brain edema.Histological examination of the lesions on the tricuspidvalve and the mass from the pulmonary artery revealed anorganizing thrombus with numerous colonies of bacteria,focal areas of acute inflammation, and microabscess forma-tion (Fig. 3a). Gram staining displayed gram-positive coc-cobacilli (Staphylococcus aureus). Histological examinationof the heart showed dispersed occlusions of small intramyo-cardial arteries bythrombicontaininglarge numbersofgram-positive bacteria with acute inflammation of adjacent areas ofmyocardium (Fig. 3b). There were no signs of nuclear atypiain the cardiomyocytes. Focal microabscesses containinggram-positive bacteria, karyorrhectic debris, and polymor-phonuclear cells surrounded small vessels in both lungs(Fig. 3c). Histologically proven focal and segmental septicglomerular infarcts were present in both kidneys (Fig. 3d).

Endocarditis-associated Brain Lesions in Slaughter Pigs

Left-sided valvular endocarditis (LSVE) is a common finding in slaughter pigs. The lesion is often associated with renal thromboembolism, but information on embolization to other organs is sparse. This study focuses on the presence and type of endocarditis-associated brain lesions (EABLs). The brains of 20 slaughter pigs with spontaneously arising LSVE and 11 controls were examined by sectioning half of a formalin-fixed brain into 4mm slices for histological examination. The aetiology of the endocarditis was determined by bacteriological and, in some cases, by fluorescence in-situ hybridization examinations. These examinations identified 11 cases of Streptococcus suis, six cases of Erysipelothrix rhusiopathiae, one Streptococcus spp. and two cases that remained aetiologically undetermined. One of the S. suis cases had a dual infection with S. suis in the aortic valve lesions and Streptococcus dysgalactiae subsp. equisimilis in the atrioventricular valve lesions. Renal infarcts were present in eight cases. Focal encephalitis was found in 12 cases, with the number of lesions ranging from one to 11. Most pigs had less than four microscopical lesions. Acute lesions were characterized by focal microabscesses without observable bacteria. Chronic lesions were characterized by astrocytosis and focal accumulation of mononuclear leucocytes. An infarct was observed in one animal. Perivascular inflammation was seen in 14 cases, mostly as two or three lesions, while focal leptomeningitis was found in eight cases. EABLs are therefore common in slaughter pigs with LSVE. The number of lesions per animal is small, which may explain the limited attention paid to this sequela of LSVE. EABLs have rarely been reported in domestic animals and mostly in patients with neurological signs. The frequent occurrence of EABLs in slaughter pigs suggests that this pathology should be investigated in other animal species with LSVE.

Delayed Colonic Perforation after ESD in a Patient with Ulcerative Colitis

Purpose: Endoscopic submucosal dissection (ESD) removes pre-malignant lesions and intra-mucosal cancers from the GI tract, offering an alternative to surgery. As any procedure, ESD has complications. Certain conditions, such as ulcerative colitis (UC), have not been well-studied with ESD and may lead to increased complications. This case demonstrates a rare incidence of delayed colonic perforation after ESD in a patient with UC. Case: 83 yo male with UC on chronic steroid therapy was found to have a large lateral spreading tumor in the ascending colon on colonoscopy with biopsies revealing no adjacent active UC disease. After the patient refused surgery, he presented for ESD. The 4 × 8 cm mass was identified, raised, and dissected with a conventional needle knife. Two small defects were closed with 7 resolution clips. Post-procedure, IV antibiotics and steroids were initiated and he was admitted to ICU. Lesion revealed a tubulovillous adenoma with underlying cauterized submucosa and no invasive malignancy. On hospital day 3, he improved with softened abdomen and improved leukocytosis. On hospital day 4, he had flatus, decreased abdominal distention and pain, and was extubated. On hospital day 5, he had respiratory distress, increased abdominal distention, and hematochezia. He was emergently re-intubated and underwent exploratory laparotomy. A small opening was noted at the hepatic flexure with bleeding and soilage. A right hemicolectomy with diverting ileostomy was performed. Post-operatively, IV antibiotics and steroids were initiated. Surgical specimen revealed metal clips with full thickness necrosis with associated adjacent hemorrhage, cautery artifact involving the muscularis propria, and acute inflammation with dense inflammatory infiltrate extending to the subserosal fat with focal microabscesses. No cautery artifact was noted in adjacent muscularis propria. The perforation was noted 3.5 cm from the clips. On hospital day 8, the patient was extubated. After a prolonged hospital course, he succumb to sepsis and other co-morbidities. Conclusions: This case demonstrates a rare delayed colonic perforation after ESD in the setting of chronic UC and steroid therapy. Although ESD is an acceptable alternative to surgery, many conditions, such as UC, have not been fully examined. In this case, the delayed perforation may have been secondary to anatomically changes in the colonic wall from UC. More research is required to fully access the safety of ESD in UC.

PRIMARY CUTANEOUS NOCARDIA INFECTION DUE TO NOCARDIA ASTEROIDES

A 34‐year‐old white man was admitted to the hospital for treatment of cyclosporine toxicity. He was referred to the dermatology service for the evaluation of two lesions that had been present for 4 weeks on the dorsum of his left hand. The patient stated that he had cut his hand on a fence and later cleaned his aquarium two weeks before the skin lesions appeared. The past medical history was significant for a cadaveric renal transplant in 1984 for renal agenesis of the left kidney and obstructive nephropathy of the right kid‐ney. His oral medications included methylprednisolone, dil‐tiazem, ranitidine, cyclosporine, and ketoconazole. The recent addition of ketoconazole for oral thrush was felt to have caused the cyclosporine toxicity.The patient was cushingoid in appearance with promi‐nent generalized hypertrichosis. The vital signs and the chest examination were normal. Skin examination revealed a 6‐mm tense vesicle with surrounding erythema with an adjacent 5‐mm firm linear papule (Fig. 1). There was no lymphadenopathy. Both lesions were biopsied, hemisec‐tioned, and sent for routine light microscopy and for fungal, atypical mycobacterial, and bacterial cultures.Laboratory studies were significant for a blood urea ni‐trogen of 56 mg/dL, creatinine of 2.6 mg/dL, WBC of 13,100/mm13, and a cyclosporine level of 2333 ng/mL (thera‐peutic level 100–300 ng/mL). X‐ray of the left hand showed no abnormality. Chest x‐ray and computerized axial tomog‐raphy scan revealed a widened superior mediastinum sec‐ondary to mediastinal lipomatosis. Tissue cultures grew Nocardia asteroides. Bacterial and mycobacterial cultures, including atypical mycobacteria, were negative.The biopsy showed a mixed cellular infiltrate with scat‐tered multinucleated giant cells and focal microabscesses. Brown and Brenn stain showed gram‐positive filamentous organisms.A modified Fite stain (Fig. 2) demonstrated acid‐fast filamentous organisms. The patient was diagnosed as having primary cutaneous nocardiosis with no evidence of dissemination. He was treated with trimethoprim sulfamethoxazole (TMP/SMX), one tablet orally four times daily, with resolution of the skin lesions within 3 weeks, but the patient developed neurolog‐ic toxicity and elevation of his serum creatinine with this therapy. He was unable to tolerate a lower dose of TMP/SMX and the medication was changed to sulfisoxazole 500 mg orally four times daily, with plans to continue the treatment for 12 months.There has been no recurrence after almost 12 months of therapy.

Granulomatous infections complicating hairy cell leukemia

Of 14 patients with hairy cell leukemia (HCL), four developed opportunistic granulomatous infections: blastomycosis, coccidioidomycosis and two Mycobacterium kansasii. The former two pathogens have not been reported with HCL, while M. kansasii infections appear to be common. While most reviews stress susceptibility to pyogenic bacteria and the predisposing role of iatrogenic factors, three of our patients were infected prior to any therapy. Thus, disease-related factors predispose to these granulomatous infections. Granulocytopenia and monocytopenia were present; the latter was not often corrected by splenectomy. There was impaired granuloma formation, with all infectious lesions appearing histologically as focal microabscesses containing few macrophages. Awareness of the frequency of opportunistic intracellular infections with early consideration of invasive diagnostic procedures to establish specific etiologic diagnosis may greatly prolong survival for many HCL patients.