Hemorrhagic Crusts Research Articles

Malignant Syphilis in an HIV-Infected Patient

Patients with HIV infection may develop common diseases with atypical clinical features. HIV infection may change the classic clinical course of syphilis and increase the incidence of a subtype of secondary syphilis named malignant syphilis. A homosexual patient with HIV infection consulted us about a one-month history of general malaise and widespread cutaneous ulcerative lesions, some with thick hemorrhagic crusts. Serology for syphilis was positive at high titers. Based on clinical, histological and serological findings, a diagnosis of malignant syphilis was made and the patient started treatment with penicillin G benzathine with progressive resolution of lesions. Malignant syphilis is a rare subtype of secondary syphilis that presents special clinical and histological features and has been associated with several processes characterized by variable degrees of immunosuppression. It is necessary to take into account this entity among the possible diagnoses in HIV-infected patients with cutaneous lesions.

Pyoderma caused byPseudomonas aeruginosainfection in dogs: 20 cases

In this report we describe the historical, clinical, histopathological and microbiological features, as well as treatments and clinical outcome, of pyoderma where Pseudomonas aeruginosa alone was isolated on bacterial culture from lesional skin. Twenty dogs were included in this retrospective study. Seven dogs without prior history of systemic or skin disease presented with acute deep pseudomonal pyoderma characterized by a sudden onset of dorsal truncal pain. Skin lesions in these dogs consisted of erythematous papules, haemorrhagic bullae, ulcers and haemorrhagic crusts confined to the dorsum. An excellent clinical response was achieved with 3-4 weeks of treatment with oral fluoroquinolones. Thirteen dogs with a more gradual onset of skin lesions associated with pseudomonal pyoderma had a history of prior skin, ear or systemic disease and had previously been treated with antibiotics and/or immunomodulatory drugs. Skin lesions in these dogs were variable and similar to those described for superficial and deep staphylococcal pyoderma. In this group, one dog was euthanized prior to commencement of treatment, two dogs were lost to follow up, and 9 had resolution of lesions following treatment with topical silver sulfadiazine (one dog), fluoroquinolones (six dogs) or cephalexin (two dogs) administered orally for 3 to 12 weeks. Rod-shaped bacteria were not always detected on cytology. Histopathology of dogs with deep pseudomonal pyoderma was characterized by severe perforating suppurative folliculitis and furunculosis.

Keratotic Plaques on the Left Trunk Area and All Extremities—Quiz Case

A 69-year-old white man presented with a 4-month history of a rapidly growing nodule on his midforehead area. The lesion was nontender but bled intermittently. The patient denied having any previous radiation exposure or trauma, and his medical history was otherwise unremarkable. Physical examination revealed a 5.0 5.2-cm, wellcircumscribed, exophytic, friable, fungating plaque with an overlying hemorrhagic crust on the superior aspect of the midforehead region (Figure1). No cervical lymphadenopathy was noted. A deep wedge biopsy specimen was sent for microscopic examination and tissue culture (Figure 2 and Figure 3). What is your diagnosis?

Paraneoplastic pemphigus resembling linear IgA bullous dermatosis

A 69-year-old Chinese man presented in 2001 with a blistering eruption over the upper and lower limbs associated with oral ulceration for 1 month. He had stage IIIA follicular small cell cleaved non-Hodgkin's lymphoma diagnosed 5 years previously, and had received several lines of palliative chemotherapy, including two courses of chlorambucil, six cycles of cyclophosphamide, adriamycin, vincristine, and prednisolone (CHOP), and two four-cycle courses of rituximab, with disease stabilization at the time of presentation. Examination revealed erythematous, annular plaques with raised, urticarial borders studded with tense bullae and vesicles over the thighs. Some lesions were arciform and annular, with vesicles arranged in a ring at the border (Fig. 1). There was involvement of the feet with desquamation at the tips of the toes (Fig. 2). Severe erosions with hemorrhagic crusts on the lips, tongue, and buccal mucosa were seen. Herpes simplex virus serology was negative. A biopsy specimen from a vesicle on the left thigh showed suprabasal acantholysis (Fig. 3), some apoptotic keratinocytes (Fig. 4), satellite cell necrosis in the epidermis, and a superficial perivascular infiltrate of lymphocytes and eosinophils. Direct immunofluorescence showed intercellular immunoglobulin G (IgG) and C3 within the epidermis and along the basement membrane zone. Indirect immunofluorescence on monkey esophagus was positive for anti-intercellular antibody at a titre of 1/160 and positive on rat bladder at a titre of 1/80. A presumptive diagnosis of paraneoplastic pemphigus was made. This was later confirmed by the presence of antibodies against envoplakin (210 kDa), periplakin (190 kDa), and desmoglein 1 on immunoprecipitation studies. He was started on prednisolone 60 mg/day (1 mg/kg/day), with complete resolution of skin lesions within 1 week, but persistence of oral ulcers. Cyclophosphamide was added at a low dose of 1 mg/kg/day as he had baseline leukopenia. Cyclosporine was later added to a maximum of 4 mg/kg/day with only mild improvement of the oral lesions. He declined rituximab therapy. He died 2 months later from fulminant pneumonia.

Herpetic Infection in Epidermolysis Bullosa

Patients with various forms of epidermolysis bullosa have fragile skin which can act as a breeding ground for multiple microbial agents. Standard wound care practices advocate the use of special dressings on open erosions as well as antibiotic topical medications to treat and prevent cutaneous infections. We report a child with recessive dystrophic epidermolysis bullosa admitted to our institution because of fevers at home. She was treated with multiple antibiotics for a cutaneous infection of the right hand. During her hospital stay, she sustained persistent fevers, and oral erosions developed, with progressive hemorrhagic crusting. Viral culture of the lip grew herpes simplex virus type 1, consistent with a diagnosis of herpetic gingivostomatitis. We present this patient to illustrate the importance of investigating wounds of epidermolysis bullosa patients for viral agents when faced with managing a child with an unclear source of fever. To the best of our knowledge, although this is the first report of herpetic gingivostomatitis in association with epidermolysis bullosa, it is likely to be more prevalent than the literature could suggest.

Wegener's granulomatosis presenting with granulomatous facial erythematous papules and plaques mimicking granulomatous rosacea

Conflicts of interest: none declared. Sir, A 70‐year‐old woman presented in 2003 with erythematous skin lesions that had developed on both cheeks within 2 months (Fig. 1a). She had a history of B‐cell chronic lymphocytic leukaemia (B‐CLL) in stage Binet C that was diagnosed in 1996. After seven courses of the chimeric anti‐CD20 antibody rituximab and interleukin‐2, followed by six courses of CHOP (cyclophosphamide, doxorubicin, vincristine and prednisolone) chemotherapy, the patient had been in partial remission since 1998. At presentation, she was being given immunoglobulin infusions by our haematologists every other week because of secondary humoral deficiency. The initial skin biopsy revealed perivascular and perifollicular granulomatous infiltrates compatible with granulomatous rosacea. However, systemic dapsone and tetracycline combined with topical metronidazole 2% twice daily for 6 weeks failed to ameliorate the patient's clinical condition. Moreover, she developed new skin lesions on the right thigh and suffered from increasing nasal obstruction. Nasal endoscopy revealed extensive haemorrhagic crusts and necrosis as well as septal perforation. An endonasal biopsy demonstrated a granulomatous inflammatory reaction with extensive necrosis. A third biopsy, taken from the right thigh, was the first to reveal clear signs of granulomatous vasculitis (Fig. 1b). The clinical symptoms pointed to Wegener's granulomatosis (WG). The patient was fully staged by computed tomographic scan, but no further sites of disease manifestation could be found. Repeated serological analyses were negative for classic antineutrophil cytoplasmic antibodies (c‐ANCA). Serological tests were also negative for perinuclear ANCA, anticardiolipin antibodies and syphilis. The white blood cell count (2·34 × 109 L−1; normal 4·0–10·0 × 109), IgM (< 0·17 g L−1; normal 0·4–2·3) and IgA (0·39 g L−1; normal 0·7–4·0) were decreased, whereas C‐reactive protein (10 mg L−1; normal < 6) and erythrocyte sedimentation rate (32 mm in the first hour; normal < 25) were slightly elevated. Angiotensin‐converting enzyme, haemoglobin and IgG were found to be normal. Renal involvement was excluded by urinalysis. A nasal smear detected oxacillin‐resistant Staphylococcus aureus.

An Itching and Excoriated Dermatosis During Intrahepatic Cholestasis of Pregnancy

A 35-year-old woman at 30th gestation week of her second pregnancy presented to our department with a 2-month history of intense and generalized pruritus. She had a spontaneous abortion 1 year earlier. Itching initially presented during nighttime and localized on lower limbs and after became continuous, diffuse, and associated with excoriations due to scratching. The patient was previously treated with oral corticosteroids (25 mg/d) in a gynecological department with temporary response. On our examination, she presented linear excoriations with hemorrhagic crusts localized on the trunk, buttocks, and upper and lower limbs. Biopsy specimen from the lesional area of the right buttock submitted for routine histology documented a mild perivascular and interstitial infiltrate of lymphocytes and monocytes with rare eosinophils on superficial dermis. Indirect and direct immunofluorescence (performed on perilesional skin) were negative. Laboratory investigations revealed microcytic anemia (hemoglobin 7.5 g/dL; medium corpuscular volume 61.7 fl), erythrocyte sedimentation rate (21 mm) and serum bile acid levels (18.3 nmol/L; normal values 1.00-8.90) increase. On the basis of clinical, serological, and histological findings, we diagnosed an itching dermatosis during an intrahepatic cholestasis of pregnancy. We treated the patient with ursodeoxycholic acid (600 mg) and topical corticosteroids with gradual resolution of itching. Furthermore, she delivered a healthy boy at 39th gestation week with normal birth weight and normal Apgar score.

Photosensitivity in an HIV‐Infected Man

Since the emergence of the AIDS epidemic, various associated skin lesions have been recognized. One interesting phenomenon is chronic photosensitivity dermatitis. We report the case of a 44‐year old homeless male with a 14‐year history of HIV and a CD4 count of 350. He presented to us with a 5‐month history of a pruritic photodistributed eruption. Physical examination revealed that he had erythematous, scaly, lichenified, and crusted plaques involving the face, neck, upper chest, and extensor extremities. Sparing of the areas under his watch and bracelet was found. A skin biopsy specimen showed psoriasiform dermatitis with an overlying thick, impetiginized, and hemorrhagic crust. There was prominent single cell necrosis throughout all epidermal layers. A lichenoid dermal infiltrate consisted mainly of lymphocytes and eosinophils. The patient’s presentation was consistent with a photosensitive psoriasiform interface dermatitis. The pathogenesis of this photodermatitis is unclear. Proposed mechanisms include the formation of a neoantigen due to UV exposure, depressed levels of endogenous scavengers leading to increased oxidative stress, and the onset of a pellagra‐like dermatosis due to niacin‐tryptophan deficiency. It is likely that several of these processes are acting in concert to cause this photoeruption.

A Case of Secondary Syphilis with Hemorrhagic Crust in the HIV-Infected Patient

A Case of Secondary Syphilis with Hemorrhagic Crust in the HIV-Infected Patient

Pyoderma Gangrenosum‐Like Cutaneous T‐Cell Lymphoma

A 25‐year‐old man presented with a large, undermined, violaceous ulcer with hemorrhagic crust on his nose for 1 year. It began as a “pimple”. He had similar lesions on his scalp, abdomen and groin. His sister has Crohn’s and his mother has rheumatoid arthritis. Screening blood tests and CT scans revealed no underlying disease. The clinical impression was pyoderma gangrenosum. Biopsies from the nose and abdomen revealed dense superficial and mid‐dermal perivascular lymphocytic infiltrate composed of enlarged, atypical lymphocytes with focal epidermotropism and epidermal necrosis. Immunohistochemistry revealed the infiltrate was primarily CD3 positive T‐cells without deficiency of CD4, CD7 or CD8. CD30, TIA and Granzyme were not detected. A T‐cell receptor gamma gene rearrangement was detected. Flow cytometry was negative. This is a case of pyoderma gangrenosum‐like cutaneous T‐cell lymphoma, a rare form of cutaneous lymphoma that clinically resembles PG, but histologically and immunohistochemically is cutaneous T‐cell lymphoma. Although rare, PG‐like ulcers should be added to the list of atypical manifestations of CTCL. This case highlights the need to evaluate all atypical lymphocytic infiltrates thoroughly with immunohistochemistry and gene rearrangement. The diagnosis must be made with caution as proliferative clones of lymphocytes can be found in true PG.

Cutaneous Langerhans Cell Sarcoma Associated with Mediastinal T‐Cell Acute Lymphoblastic Lymphoma: Clonally Related Neoplasms

An 8‐year‐old male presented with several 1–4 cm, indurated, brownish‐red nodules with superficial, punctate hemorrhagic crusts localized to the groin, which developed over several weeks. An initial biopsy was consistent with Langerhans cell histiocytosis. A work up, including a chest and abdominal CT scan demonstrated a large mediastinal mass which was diagnosed as precursor T cell lymphoblastic lymphoma. Treatment with a chemotherapeutic protocol resulted in shrinkage of both the mediastinal and cutaneous lesions. Late in the course of treatment the cutaneous lesions rapidly recurred and spread to various sites. A second skin biopsy showed an extensive diffuse infiltrate of histiocytic‐appearing cells extending from the papillary dermis into the superficial subcutis. The cells had markedly pleomorphic, vesicular nuclei and abundant amphophilic cytoplasm. Numerous mitotic figures were present. The neoplastic cells were S‐100 protein and CD1a positive by immunohistochemistry. The histopathologic diagnosis was Langerhans cell sarcoma. Gene rearrangement studies demonstrated clonal rearrangement of the T cell receptor gamma gene in specimens from both the mediastinal mass and one of the recurrent cutaneous lesions. The sizes of the PCR products were identical demonstrating a clonal relationship between the two neoplasms.

Photodynamic therapy (PDT) using topically applied δ-aminolevulinic acid (ALA) for the treatment of malignant skin tumors

The objective of our study was to determine therapeutic response to photodynamic therapy (PDT) and adverse reaction of PDT in 126 patients with 141 lesions: 36 patients with 41 lesions of superficial basal cell carcinoma (BCC), 35 patients with nodular BCC, 42 patients with ulcerated BCC, four patients with 14 lesions of actinic keratoses, five with superficial squamous cell carcinoma (SCC) and four with Bowen's disease. Patients with skin malignancies were treated using 20% aminolevulinic acid (ALA) (Medac GmbH, Wedel, Germany) topically and light from an argon-pumped dye laser. A complete response was achieved in 81.5% treated lesions. A partial response after PDT in 10.6% treated lesions, no response in 7.8% treated lesions and 11.3% lesions recurrences during 10-36 months follow-up were observed. Following light exposure skin lesions became necrotic and showed hemorrhagic crusts and the cosmetic outcome was excellent or good in 97 of the completely responding lesions (84.3%). Clinical studies reported by other groups have shown similar high percentages of clinical cure. PDT appears to be a more feasible alternative to conventional therapy of skin malignancies.

Benign Cutanous Degos' Disease: A Case Report and Review of the Literature

We report a case of benign form of Degos' disease, a rare condition often characterized by multisystemic vasculopathy, and discuss the case by the light of the limited literature available. A 34-year-old male patient was admitted to our clinic with lesions on his neck and back and a history of not getting any benefit from previous acne medications. Dermatological examination revealed erythematous papules with hemorrhagic crusts on their surfaces and many well-defined atrophic scar tissues. Histopathological evaluation of a biopsy obtained from a lesion revealed the findings of Degos' disease. Further evaluation did not reveal any sign of systemic involvement. He was diagnosed with the benign form of Degos' disease.

Clinical, haematological, immunohistochemical and pathological findings in 10 cattle with cutaneous lymphoma

This paper describes the clinical, haematological, immunohistochemical and pathological findings in 10 female cattle with cutaneous lymphoma. The most striking clinical finding was multifocal intracutaneous nodules, which were firm, hairless...

Crimean-Congo Hemorrhagic Fever in Kosovo

Crimean-Congo hemorrhagic fever (CCHF) virus is transmitted to humans by Hyalomma ticks or by direct contact with the blood of infected humans or domestic animals. CCHF virus has been reported from the Near, Middle, and Far East (countries such as Iraq, Pakistan, United Arab Emirates, Kuwait, Oman, and China [1, 6-8, 11]) and from several African countries (4, 9). Besides, there are several reports on CCHF virus in the former Yugoslavia (5, 10), but CCHF virus strains from this area have not been characterized up to now. We describe here a case of CCHF in the year 2000 in Kosovo that preceeded an outbreak in the same region in 2001 (2). On 23 May 2000, a farmer's wife (age, 17 years) living near Pristina, Kosovo, was bitten by a tick in the left femoral region while working in her garden. The tick was later identified as a member of the Hyalomma species at our institute. The disease started on 28 May with chills, myalgia, nausea, anorexia, vomiting, headache, and backache. The victim visited an outpatient clinic in Prizren, where broad-range antibiotic therapy was initiated because a septic infection could not be excluded. On 30 May, she developed massive hemorrhage with hematemesis (7 to 8 times per day), melena, hematuria, metrorrhagia, and petechia. She was hospitalized in a medical ward with no special isolation measures in a difficult clinical condition on 31 May, without palpable pulse or measurable blood pressure, with a body temperature of 39.7°C, and with severe hemorrhagic manifestations (petechiae, melena, hematemesis, and metrorrhagia). On 1 June, epistaxis and gingival bleeding were additionally observed and the high fever continued (40.1°C). The patient was fully orientated, without neurological symptoms, but prostrate. She complained of back pain and headache. Her eyes showed signs of hemorrhagic conjunctivitis and her gingiva and tongue were covered with hemorrhagic crusts, but the petechiae in the pectoral region were already in remission. Large ecchymoses appeared at the sites of venipuncture. The heart had a sinusal rhythm (90 beats/min) and weak tones, without noise. The abdomen was tender on palpation and the liver was palpable and slightly enlarged, but the spleen was not palpable. Diuresis was evident, with 1,500 ml of urine excreted per day. On 3 June she developed a polyuria (4,500 ml per day). The next day, the hemorrhagic diathesis had almost disappeared with only a light residual metrorrhagia. Blood pressure was 100/70 mmHg (pulse frequency, 60 beats/min). She was feeling better. Supportive therapy given to the patient during the course of the disease consisted of hydration and control of temperature. No blood transfusions were administered. No secondary cases have occurred in the hospital where the patient was treated.

Acné necrótico (varioliforme)

Abstract—A 44-year-old man developed pruritic papules and pustules over the scalp, face and neck. Some lesions became haemorrhagic crusts and healed producing depressed scars.The histopathology showed a lymphocytic infiltrate with exocytosis and follicular necrosis. On the basis of clinical and histopathological findings, the diagnosis of acne necroticans was made. The management with several antibiotics produced several remisions and relapses. A 2-year remision has been obtained with 6-month isotretinoin treatment. This entity is a chronic necrotizing lymphocytic folliculitis that has beenclassified in two clinical forms, one superificial or miliaris and other deep and scarring or varioliformis.

Paraneoplastic pemphigus: a review of the literature.

Paraneoplastic pemphigus is a relatively rare but highly significant acquired mucocutaneous disorder. The condition typically presents in patients with previously diagnosed lymphoreticular disease, primarily malignancies (non-Hodgkin's lymphoma; chronic lymphocytic leukemia). Multiple sites of involvement are common, with the skin affected by a polymorphous eruption that includes lichenoid plaques as well as bullae. The oral lesions occur in all cases and present as painful widespread shallow ulcers with hemorrhagic crusting of the lips. Conjunctival involvement is also seen and may result in scarring. Pulmonary lesions are an ominous sign. Histopathologically, intraepithelial and subepithelial clefting associated with interface dermatitis are seen. A variety of autoantibodies directed against desmoplakins and desmogleins can be identified with immunoprecipitation studies. Treatment with immunosuppressive agents may result in some resolution of the disease, but the prognosis for paraneoplastic pemphigus is considered to be poor.

Chronic Acneiform Eruption With Crateriform Scars

REPORT OF A CASE A 52-year-old white woman presented to our clinic with a 35-year history of a recurrent, follicular-based eruption involving her face and scalp. She first noted the onset of these occasionally painful lesions in late adolescence. The lesions would characteristically present as crops of acneiform lesions on the forehead, temples, ears, nose, and posterior aspect of the neck. They would then evolve through hemorrhagic crusts to form depressed scars over the course of several weeks. Occasional lesions were noted on the chest and upper abdominal area, especially during severe outbreaks. No constitutional symptoms were described in association with these eruptions. Multiple cultures of representative lesions typically yieldedStaphylococcus aureus, and antistaphylococcal antibiotic therapy adequately controlled recurrent outbreaks. Discontinuation of systemic antibiotic therapy usually resulted in a recrudescence of the lesions. The remainder of the patient's medical history was unremarkable except for occasional migraine headaches, which were controlled

Unilateral Keratotic Vascular Lesion on the Leg

<h3>REPORT OF A CASE</h3> A 63-year-old man presented with violaceous, brown plaques on his lower left leg. The plaques had been present since birth and over time had enlarged, becoming keratotic and verrucous. Minor trauma would result in ulceration, bleeding, and scale crust. Physical examination revealed a patchy, variably scaly and papillomatous lesion extending from the dorsum of the foot to the anterior midtibial surface (<b>Figure 1</b>). A biopsy specimen of the lesion is shown in<b>Figure 2</b>through<b>Figure 4</b>. What is your diagnosis? <h3>DIAGNOSIS:</h3> Verrucous hemangioma. <h3>HISTOPATHOLOGIC FINDINGS</h3> The skin showed hyperkeratosis, papillomatosis, and occasional mild acanthosis overlying an angiomatous proliferation that stretched across the upper dermis and extended deep into the reticular dermis (Figures 3 and 4) and subcutaneous tissue. Focal areas of ulceration and hemorrhagic scale crust were present. The hemangioma was composed of capillary and small cavernous blood vessels.

Juvenile pemphigus vulgaris associated with Graves' disease

Pemphigus vulgaris occurs with equal frequency in women and men, usually during the fifth or sixth decade of life. 1 Childhood and adolescent cases are rare; only 31 well-documented cases have been reported. 25 In one series of 274 patients with pemphigus, only four (1.4%) were in the juvenile category. 6 Children usually have persistent oral lesions, and skin may or may not be involved. Furthermore, pemphigus occurs more frequently in girls. 3 In adults myasthenia gravis and thymoma have been associated with the disease, 7, 8 but a review of the literature does not reveal any reports of pemphigusassociated Graves' disease. Drug-induced pemphigus vulgaris has been associated with penicillamine, thiopronine, captopril, penicillin, and rifampin, but no correlation with antithyroid medications has been cited. 92° We describe the clinical and immunohistopathologic findings in a patient in whom disabling mucosal erosions developed during treatment of Graves' disease with propylthiouracil. CASE REPORT A 5-year-old boy had a 3-month history of severe nasal and oral erosions, recurrent epistaxis, hoarseness, weight loss, and dysphagia. He had had Graves' disease for 10 months. For approximately 9 months the patient had been treated with 600 mg of propylthiouracil and 100 #g of levothyroxine until 2 weeks before, when the propylthiouracil was discontinued because of the possibility of a drug-induced stomatitis. Despite withdrawal, the child's hoarseness and dysphagia persisted. Examination revealed diffuse erosions of the nasal and oral mucosa without intact bullae (Fig. 1). The nares were rimmed with a hemorrhagic crust. The child was thin and had tachycar