Multiple Skin Nodules Research Articles

Huge and Multiple Xanthomas Misdiagnosed as Rheumatoid Nodules and Mistreated with Multiple Surgical Excisions over 4 Years, A Case Report

Background: Xanthoma is the iceberg of familial hypercholesterolemia; it’s resemblance to other cutaneous lesions such as rheumatoid nodules might lead to misdiagnosis. We emphasize in this case report the importance of comprehensive clinical and investigatory approach to cutaneous lesions as they could be the only manifestation of systemic diseases, and this helps to avoid delayed management and unnecessary interventions. Aim: Xanthomas as a possible diagnosis for multiple skin nodules, as it can be easily supported by performing simple noninvasive blood tests; the lipid panel. Case report: Female patient, presented with multiple skin lesions and a strong family history of premature coronary artery disease. She was firstly managed with multiple surgical resections as having benign masses, and later was misdiagnosed as having rheumatoid nodules and referred to rheumatology clinic for evaluation, wherein a clinical suspicion of xanthomas originated, and was supported by the severely elevated serum LDL level and a tissue diagnosis of xanthoma. She has been started on statins with regular clinic. Conclusion: The purpose of this case study is to explain the importance of including xanthomas within the differential diagnosis of recurrent skin lesions. Whereas the tissue diagnosis is the gold-slandered investigation, simple noninvasive blood test, serum lipid measurement can be the clue for diagnosis of the hidden fatal but easily controllable disease; familial hypercholesterolemia.

Nodal T follicular helper cell lymphoma with aberrant CD20 expression and monoclonal TCR, IG rearrangements secondary to Classical Hodgkin Lymphoma: a case report.

Classical Hodgkin Lymphoma (CHL) is a rare malignant neoplasm of the lymphatic system. While CHL typically responds well to conventional treatments, some cases may experience relapse to other subtypes, with the development of secondary peripheral T-cell lymphoma (PTCL) being relatively uncommon. Herein, we report a rare case of nodal T follicular helper cell lymphomas,nos (nTFHL-NOS) secondary to CHL, accompanied by aberrant CD20 expression and clonal rearrangements of T-cell receptor (TCR) and immunoglobulin (IG). A 74-year-old male, was diagnosed with CHL, leaning toward the mixed cell type, 6years ago. He received six cycles of the Adriamycin, Bleomycin, Vinblastine, Dacarbazine (ABVD) regimen, achieving complete clinical remission. The patient was admitted to our hospital due to the appearance of multiple skin nodules 66months later. Histopathological analysis revealed nTFHL-NOS, with aberrant CD20 expression and clonal rearrangements of TCR and IG. The patient underwent two cycles of chemotherapy with brentuximab vedotin and the Gemcitabine-Oxaliplatin (G-mox) regimen, resulting in a reduction of the skin lesions to 2cm × 1cm. We discuss this rare case and review related literature.

Cutaneous metastasis in a case of carcinoma floor of mouth- A rare case report

The incidence of cutaneous metastasis in head and neck cancers is less than 1%. Carcinoma of the oral cavity is one of the most common cancers of the head neck region with frequent metastasis to internal organs, especially the lungs, liver, and bone.We present a case of Carcinoma of floor of mouth with cutaneous metastasis.A 55 year old lady presented to our department with complaints of non-healing ulcer in the oral cavity and ulcerated nodules over neck and chest. On examination, mouth opening tongue mobility was restricted with grade 2 trismus. An ulcer in left gb sulcus, bilateral lymphadenopathy and multiple ulcerated skin nodules on neck and chest wall were noted. CECT Face and Neck showed heterogenously ehancing mass at the floor of mouth involving left buccal mucosa and erosion of mandible, lymph node mets and skin nodules. ECOGPS was 1.She was treated with palliative systemic chemotherapy and thereafter Palliative radiation. Now she is having stable disease and is on metronomic chemotherapy with regular follow up.Our case has highlighted that cutaneous metastasis can be seen in the cancers of floor of mouth. Palliative chemotherapy and radiotherapy can significantly increase Progression free survival and hence the Quality of life of patients with such presentation.

An unusual presentation of epidermoid cyst as multiple skin nodules masquerading as neurofibroma.

Epidermoid cysts, also known as keratin cysts, are benign cystic malformations containing keratin and lipid-rich debris. These lesions generally present as painless, nontender, soft tissue masses. They can involve any part of the body but most commonly involve face, chest, back, and genital areas. They can have both congenital and acquired presentation. They are in general seen as a solitary skin nodule but can rarely present as multiple skin nodules. We present a case of a 52-year-old male patient who presented with multiple skin nodules involving face, chest, and back. After making a provisional diagnosis of an epidermoid cyst, surgical excision was performed. Histopathological examination confirmed the diagnosis of an epidermoid cyst. The patient's follow-up was uneventful, with no episodes of recurrence or infection. This report emphasizes the rarity of multiple widespread epidermoid cysts and the importance of considering differential diagnoses and appropriate intervention methods.

IgG4-related mastitis characterized by skin thickening of the breast: a case report

BackgroundIgG4-related diseases are characterized by marked infiltration and IgG4-positive plasma cells and fibrosis, and involve multiple organs. However, IgG4-related mastitis is rare. We report a case of mastitis associated with IgG4-related disease.Case presentationA 78-year-old woman visited our hospital with a complaint of multiple subcutaneous nodules. A biopsy of a dorsal subcutaneous mass was performed but did not yield a definitive diagnosis. However, blood tests showed a high level of IgG4, thus she was referred to the department of collagen disease for further examination. Computed tomography (CT) showed a thickening of the skin of the right breast, and the patient was referred to our department. On physical examination, a large area of thickened skin was observed in the right breast without inflammatory breast cancer-like redness, and no mass was palpable. A needle biopsy was performed on an indistinct hypoechoic area in the breast, and she was diagnosed with mastitis associated with IgG4-related disease. Systemic steroid therapy was then administered and the symptoms of multiple skin nodules and mastitis improved.ConclusionsWe reached the diagnosis based on a biopsy of the mammary gland enabling the patient to begin treatment for IgG4-related disease. This case was characterized by breast skin thickening, which is different from inflammatory breast cancer.

A Study of the Susceptibility of Laboratory Animals to the Lumpy Skin Disease Virus.

This article presents the results of a study on the susceptibility of laboratory animals to the lumpy skin disease virus (LSDV). Mice weighing 15-20 g, hamsters weighing 40-60 g, guinea pigs weighing 600-1200 g, and rabbits weighing 2.5-3 kg were used in this study. Nodules were observed on the skin of rabbits and hamsters at the sites of inoculation. The virus was isolated from the affected skin areas in cell culture and examined using real-time PCR, indicating its tropism for animal skin. The production of anticapripoxvirus antibodies was detected using the neutralization reaction, starting from 10 days after infection in mice, 27 days in rabbits, and 14 days in hamsters. Some laboratory animals exhibited multiple skin nodules. This indicates that these animal species may play a role in maintaining the epizootic process.

Deciphering the spectrum of cutaneous lymphomas expressing TFH markers

T-follicular helper (TFH) markers are expressed in the microenvironnement of marginal zone B-cell lymphoma (MZL), and in lymphomas arising from TFH-cells, sometimes making the differential diagnosis difficult. In the skin, the “TFH-spectrum” is poorly defined, going from primary cutaneous lymphoproliferative disorder with small/medium CD4+ T-cells (SMLPD) to cutaneous localizations of systemic angioimmunoblastic T-cell lymphoma (cAITL), and may pass through intermediate forms (primary cutaneous T-follicular helper derived lymphoma, not otherwise specified (PCTFHL,NOS)). We retrospectively analyzed 20 MZL, 13 SMLPD, 5 PCTFHL, and 11 cAITL clinically, histologically, and molecularly, to define tools to differentiate them. Characteristics that might favor the diagnosis of MZL over SMLPD are: multiple skin nodules (p < 0.001), nodular architecture (p < 0.01), residual germinal centers with follicular dendritic cell network (p < 0.001), monotypic plasma cells (p < 0.001), and few staining with PD1 (p = 0.016) or CXCL13 (p = 0.03). PCTFHL and cAITL presented as multiple (p < 0.01) lesions, in older patients (p < 0.01), with systemic symptoms and/or biological alterations (p < 0.01). Immunophenotypic loss of T-cell markers (p < 0.001), BCL6 (p = 0.023) and/or CD10 staining (p = 0.08), and a higher proliferative index (≥ 30%, p = 0.039) favoured these diagnoses over SMLPD. Pathogenic variants were observed by genomic sequencing in 47% of MZL (TNFAIP3 (32%), EP300 (21%), NOTCH2 (16%), KMT2D (16%), CARD11 (10.5%)), 8% of SMLPD (TET2), 40% of PCTFHL (SOCS1 (20%), ARID1A (20%)) and 64% of cAITL (TET2 (63.6%), RHOA (36.4%), NOTCH1 (9%)). This study characterizes the various clinical and histological features between cutaneous lymphomas expressing TFH markers and highlights the value of the interest of screening for genomic mutations in difficult cases.

A retrospective analysis of Stewart-Treves syndrome in the context of chronic lymphedema

BackgroundStewart-Treves syndrome (STS) is an angiosarcoma associated with chronic lymphedema. ObjectivesThis article analyses the characteristics of twenty-two patients and proposes active intervention in lymphedema and the early diagnosis of STS. MethodsTwenty-two patients with STS were diagnosed at the centre over an 11-year period. Clinical manifestations, a series of conventional analyses, and histopathology were used to study these cases retrospectively. ResultsThe age range of 22 patients with STS was 15 to 78 years. The main clinical manifestations included multiple skin and subcutaneous nodules and scattered red or purplish-red rashes in the lymphoedematous limbs. These patients often showed clinical symptoms such as lymphedema, weakness, emaciation, pain, mass, lymphadenopathy and so on. The positive rates of ultrasonography, MRI and radionuclide imaging were 66.7% (6/9), 92.3% (12/13) and 18.2% (2/11), respectively. The main points regarding active intervention in lymphedema and early diagnosis of STS were summarized. Study limitationsSince this was a retrospective study, the main points summarized by the author need to be further quantified in clinical work to guide the diagnosis of this kind of disease more conveniently. In addition, further clinical trials are needed to evaluate the role of lymphedema in the occurrence and development of malignant tumors. ConclusionsSTS can appear in lymphoedematous tissue many years after lymphedema onset. To avoid delays in the diagnosis and therapy of STS, physicians should actively look for signs or symptoms of malignant lymphedema during the follow-up period and promptly manage patients developing problems.

A Case of Multiple Skin Lesions After LipodissolveTM Injection

Mycobacterium abscessus (M. abscessus) is a rapidly growing nontuberculous mycobacterium commonly found in soil and water. It can cause localized infection when inoculated during surgical or cosmetic procedures. We describe a case of a patient who developed multiple skin nodules resulting from injection of LipodissolveTM for cosmetic purposes. We highlight the following points: M. abscessus can have inducible resistance to macrolides and may require novel agents for treatment; outbreaks can occur when injectables contaminated with M. abscessus are inoculated into the skin; and local health departments and the U.S. Food and Drug Administration should be contacted for outbreak investigation.

Borderline Lepromatous Leprosy with Severe Erythema Nodosum Leprosum: A Case Report

Background: Leprosy is a chronic granulomatous infectious disease caused by Mycobacterium leprae (M. leprae) that primarily infects Schwann cells in the peripheral nerves, leading to nerve damage and the development of disabilities. In 2018, Indonesia was the third country with the most leprosy cases in the world. Erythema nodosum leprosum (ENL), also known as type II leprosy reaction, is a severe immune-mediated complication of multibacillary leprosy. Purpose: To report a case of borderline lepromatous leprosy with severe ENL. Case: A 49-year-old Balinese man presented with multiple tender erythematous skin nodules all over his body, fever, arthralgia, bilateral cervical lymphadenopathy, and sensory loss for the past week. The acid-fast bacilli bacteriological examination showed a positive result. The patient was diagnosed with borderline lepromatous (BL) leprosy with severe ENL and was treated with multibacillary multidrug therapy (MB MDT), methylprednisolone, and other symptomatic medications. After 1 month of treatment, there was an improvement in skin lesions. The MB-MDT treatment was continued and methylprednisolone was planned to be tapered down gradually. Discussion: Approximately 20-50% of all leprosy patients show leprosy reactions in the course of the disease. The goals of treatment for severe ENL are to control inflammation, reduce pain, treat neuritis to prevent nerve dysfunction and contractures, and prevent recurring ENL. The prognosis of leprosy with ENL reactions depends on the severity of the occurring leprosy reaction; early diagnosis and prompt treatment; and patient compliance with treatment. Conclusion: Early diagnosis and treatment are essential to avoid deformities in leprosy patients.

Lumpy skin disease - A potential downfall of national economy.

Madam, the Lumpy Skin Disease, initially endemic in Africa and widely spreading to encompass the Middle East and other regions, finally has Pakistan in its grasp. It has emerged in Sindh and South Punjab, wreaking havoc in Sindh and infecting more than 20,250 animals, with more than 50 deaths being reported [1]. Internationally, the Southern, Eastern, and Southeastern countries faced economic losses as high as USD 1.45 billion due to this disease [2]. Its long-lasting and deplorable impact on the economy has been considered a prominent infection of livestock by The World Organization for Animal Health (OIE). Despite low associated mortality of 10%, it has a consequential worldwide morbidity rate of about 5-45% [3]. Transmitted by an arthropod vector, LSD is a vector-borne viral disease, which largely targets cattle including water buffaloes. The virus is shed in body secretions involving the infected animal's tears, saliva, semen, and milk [4]. The disease is characterized by a high grade, persistent fever, multiple skin nodules, lymphadenitis, a decline in milk yield, orchitis, and abortion. The economic implications encountered by farmers in the afflicted areas include low milk yield, poor skin and hide quality, and consistent degenerative thinness of animals. Although the entire cattle industry suffers from economic losses, small-scale farmers endure the greatest loss. Despite the low animal-to-human transmission, probability, the high economic losses incurred require drastic steps to prevent the further spread of the disease among cattle. Mass awareness programs among farmers should be promptly implemented, and vaccination drives should be promptly scheduled. Insect repellents and vector traps should be made available on a large scale. Steps must be taken to properly set isolation areas following the standard health protocols for infected livestock. Complications caused by the disease can be effectively treated by the usage of antimicrobials, anti-inflammatory medications, supportive therapy, and antiseptic solutions. Severely infected animals should be culled in a remote area following international standards. Highly effective clinical surveillance is required for timely detection and isolation of a suspected case [5]. Although there is no documented proof of transmission to humans, consumers should preferably avoid dairy products and meat before complete eradication of the disease. We humbly request the concerned health department take timely measures before an unprecedented loss is incurred and promote the national production of vaccination that is easily obtainable by farmers of all economic backgrounds.

A fatal case of disseminated nocardiosis due to Nocardia otitidiscaviarum resistant to trimethoprim–sulfamethoxazole: case report and literature review

BackgroundDisseminated nocardiosis still causes significant morbidity and mortality and is often caused by Nocardia asteroides, N. basiliensis, and N. farcinica and are often treated with trimethoprim–sulfamethoxazole (TMP–SMX). Nocardia otitidiscaviarum (N. otitidiscaviarum) rarely causes disseminated disease and resistance to TMP–SMX is even more rare.Case presentationA 37-year-old woman with metastatic breast cancer and right ear deafness with recent occupational gardening and manipulating soil, presented to the hospital with first time seizure and multiple skin nodules. Magnetic resonance imaging (MRI) showed ring enhancing lesions, biopsy of the skin and brain lesions grew N. otitidiscaviarum. She was empirically treated with TMP–SMX and Imipenem–Cilastatin, however, almost three weeks into therapy, susceptibility results revealed it to be resistant to both antimicrobials, she was subsequently changed to Amikacin, Linezolid, Moxifloxacin, and Doxycycline but ultimately died.ConclusionsThis case report highlights the importance of suspecting a rare Nocardia species in patients at risk with proper occupational exposure, moreover, TMP–SMX resistance should be suspected with lack of clinical response, this may have important implications on clinical practice when facing similar infections.

Highly aggressive gastric adenocarcinoma with multiple skin nodule and supraclavicular node in a 19-year-old patient

Although gastric adenocarcinoma is common in middle- and old-aged population, it is rare in young people. Development of cutaneous metastasis during presentation is even rarer in any age group. We report the case of a 19-year young man with gastric adenocarcinoma who had multiple skin nodules over the trunk during presentation. Fine-needle aspiration cytology of the nodule revealed it to be metastasis from gastric adenocarcinoma. Cutaneous metastasis may be the first presentation of internal malignancies even with a short history of disease in young patients. Atypical presentation of a malignancy in atypical age group must be evaluated with prompt assessment, active intervention, and close follow-up.

Epithelioid sarcoma, masquerading as sporotrichosis

Epithelioid sarcoma (ES) is a rare soft tissue neoplasm appearing as multiple slow growing skin nodules. It is a locally invasive tumor, but may metastasize to regional lymph nodes and lungs.&#x0D; A 19 year old male presented with multiple painful skin nodules, with linear distribution on right upper limb for 2 years. Initial histology mimicked fungal infection, but response to antifungal treatment was poor. His last skin biopsy showed nodular tumor in the dermis with central necrosis and cytological atypia. Immunohistochemistry confirmed the diagnosis of ES. Since he had radiological evidence of lung metastases, chemo radiotherapy was given. Out of the two phenotypes of ES, distal type may show a sporotrichoid pattern. Histology may mimic non neoplastic granulomatous dermatoses. Cells are positive for cytokeratins, epithelial membrane antigen, vimentin and CD34.&#x0D; Diagnosis would be difficult as ES mimics other common non neoplastic granulomatous dermatoses including sporotrichosis.

Epithelioid Trophoblastic Tumour Presenting with Scalp Lesions.

Trophoblastic disease is a rare entity with several presentations at diagnosis.Presentation with dermatological changes may need differential diagnosis to distinguish it from other types of dermatological disease.Quick diagnosis and referral to an appropriate centre are needed.

912 Unusual Presentation Of JAK-2; A Degenerating Breast Neurofibroma

Abstract Introduction 29-year-old lady presented to ED with acutely enlarging painless right breast swelling. No history of trauma; diagnosis likely breast abscess. Significant growth during short inpatient admission with incidental clinical finding of multiple cutaneous skin nodules from childhood, mother had similar lesions. CT chest performed illustrating large anterior chest wall mass 15.2x15.7x24.7cm. Transferred to regional plastic surgery unit for resection. Haematological abnormality identified on routine bloods which was life changing. Description Attended ED following a three-day history of a rapidly progressive right breast mass causing necrosis and blistering of overlying skin with drop in haemoglobin from 138 to 94 overnight. Transferred to regional plastic surgery unit where she underwent an evacuation of breast haematoma and excision of neurofibroma and was transfused 2 units of blood. Pathology revealed a degenerating neurofibroma. Abnormal coagulation and blood film during inpatient stay prompted subsequent bone marrow biopsy which revealed diagnosis of myeloproliferative neoplasm later found to be JAK-2 V617F mutation positive. Discussion Patient moved to UK 6 years ago from Lithuania, previously lived within area affected by Chernobyl nuclear disaster. JAK-2 myeloproliferative disease typically presents in middle aged but also reported as radiation acquired. Risk benefit of anti-platelet therapy for myeloproliferative malignancy evaluated due to high probability of re-bleeding. Complex case of Neurofibromatosis-1 and Myeloproliferative disease; diagnosis presented as a breast lump. Multidisciplinary input from surgery, haematology, genetics and neurology for best outcome.

Cutaneous Metastases as Initial Presentation of Lung Carcinoma

Breast cancer, in women, and lung cancer, in men, are the most common origins of cutaneous metastasis. Lung cancer can metastasize to any organ but mostly to the contralateral lung, liver, adrenal gland, bones, and brain. Over 1-12% of patients with lung cancer can develop skin metastasis. Non-small cell lung cancer includes 87% of lung cancer cases. Adenocarcinomas subtype accounts for approximately 40% of all lung cancers and is the most common histology in women. A woman’s lifetime risk of developing lung cancer is 1 in 16 women but lower than that of a man (1 in 13 men). The survival rates of women with lung cancer are usually higher than those of men. Herein, we report the case of a 66-year-old female who presented with painless multiple skin nodules over the chest back and axilla for three months. On evaluation, biopsy and immunohistochemistry were done from skin nodules suggestive of adenocarcinoma. CT thorax showed lung mass and was diagnosed as a case of metastatic adenocarcinoma, primary being from the lung. Our case demonstrated that skin metastasis could be the first sign of internal malignancy. Metastasis to the skin is often a preterminal event that heralds a poor prognosis.

Successful treatment of congenital systemic juvenile xanthogranulomatosis with pulmonary involvement

Juvenile xanthogranuloma (JXG) is a common form of non-Langerhans cell histiocytosis, which usually presents with spontaneously regressing skin lesions. Systemic involvement is rare and mostly seen in patients with multiple skin nodules. It can spontaneously regress, but sometimes systemic involvement can cause life-threatening symptoms and can be fatal. Herein, we report a case of congenital systemic JXG with multiple skin nodules, soft tissue and pulmonary involvement. She was successfully treated with chemotherapy according to Langerhans cell histiocytosis treatment protocol IV of the Histiocyte Society (LCH-IV).

Extracutaneous involvement of subcutaneous panniculitis-like T-cell lymphoma associated with hemophagocytic lymphohistiocytosis and refractory to intensive chemotherapy

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is an uncommon primary cutaneous lymphoma characterized by subcutaneous infiltration of mature cytotoxic T-cells with rearranged alpha/beta T-cell receptor phenotype. SPTCL is typically a disease of young adults with 36 years old being the median age. Patients commonly present with B-symptoms and multiple painless skin nodules in the extremities and trunk. Extracutaneous involvement is rare. Here, we present a case of SPTCL in a 32-year-old woman with diffuse but clinically occult skin lesions detected on imaging through multiple modalities and pathology-proven extracutaneous involvement in the mesentery. Retrospective chart review, review of patient specimens, and literature review for similar cases were performed. Histologic examination revealed SPTCL in the skin and omentum. Our patient’s clinical course was associated with hemophagocytic lymphohistiocytosis (HLH), a known poor prognostic indicator, and refractoriness to intensive chemotherapy. Due to the rarity of this disease, treatment is not yet standardized. However, for our patient, an allogeneic stem-cell transplant resulted in positron emission tomography/computed tomography-negative remission 11 months post-transplant or 20 months post-initial presentation. We report an unusual case of subcutaneous panniculitis-like T-cell lymphoma (SPTCL) with clinically occult subcutaneous lesions and prominent biopsy-proven extracutaneous mesenteric involvement. Further investigation is required to better understand the mechanism of disease, prognosis, and optimal treatment approach for SPTCL patients presenting with extracutaneous involvement and HLH.

Strain elastography for the assessment of skin nodules in dogs.

Strain elastography (SE) is a modern imaging technology that provides an additional way of evaluating the changes in soft tissue elasticity caused by pathophysiological processes. Despite its widespread use in human medicine, only a few studies on the application of SE in veterinary medicine are available. To evaluate the potential usefulness of SE as an integrative imaging model in the standard ultrasound technique to better discriminate between inflammatory and neoplastic skin nodules in dogs. Fifty-one client-owned dogs with clinical evidence of single or multiple skin nodules detected during routine dermatological examination. Margins, echogenicity, echo-structure, calcification and vascularisation of 65 skin nodules were assessed with ultrasound, and SE was used to score qualitative (E-score, E-index, E2) and semiquantitative (SR) parameters. A comparison of diagnostic yields with cytological and histological findings as the gold standard was performed. Mast cell and benign follicular tumours showed the highest E-scores and SRs among neoplastic nodules; statistically significant differences were not detected. Calcific and nonvascularised nodules showed significantly higher E-index values than the others. Overall, a negative correlation was observed between the longitudinal diameter of skin nodules and the qualitative elastic parameters. In this study, SE proved to be useful to identify only a subset of nodules such as mast cells and hair follicular tumours. Although evidence supporting the use of SE in evaluating skin nodules was demonstrated to below, indicators to guide further research were developed.