Small Papules Research Articles

Familial Sarcoidosis in Taiwan

Sarcoidosis is a multisystemic granulomatous disease of unknown etiology and is uncommon in Taiwan. No cases of familial sarcoidosis have been reported in Taiwan. In this article, we report a mother and son pair who had sarcoidosis. The 56-year-old mother sought medical help for chronic cough for 3 months in 1993. Enlarged mediastinal lymph nodes were demonstrated on chest computed tomography. Besides, two small erythematous papules on her face were observed. Mediastinoscopic biopsy and skin biopsy showed non-caseating granulomatous inflammation. Sarcoidosis was thus diagnosed. The human leukocyte antigen (HLA)-typing of the patient was HLA-A2, A11, B35, B39, CW4, CW7, DR8 and DQ6. Eleven years later, her son was also diagnosed with sarcoidosis proved by mediastinoscopic biopsy. His HLA-typing was HLA-A2, A24, B39, B48, CW7, CW8, DR8 and DQ6. This is the first report of familial sarcoidosis in Chinese people. More cases are needed for further investigation of genetic predisposition among Chinese people.

Frontal Fibrosing Alopecia in a Premenopausal Woman: Immunohistochemical and Immunofluorescence Analysis

Frontal fibrosing alopecia (FFA) was first described in 1994 and is considered a variant of lichen planopilaris in a patterned distribution that primarily affects postmenopausal women. Cicatricial alopecia of the frontoparietal hairline is characteristic; the affected area appears as a shiny, bandlike zone of incomplete hair loss with skin-coloured small hyperkeratotic papules. We describe a case of a premenopausal woman with this rare disease. To date there are very few reports of FFA in premenopausal women. The immunohistochemical investigation with lymphocytic markers (CD4, CD8, CD20, CD45RA, CD57) revealed CD8 positive lymphocytes penetrating the follicular epithelium. Direct immunofluorescence showed clumped deposition of IgM along the follicular basement membrane zone.

Fever of Unknown Origin in a Migrant Farm Worker from Mexico: History, Her Story and His Story

A 29-year-old migrant farm worker from Mexico presented to a hospital in Ontario with fever of unknown origin. She had arrived in Canada six weeks previously to work at an orchard. Her past medical history included two caesarean sections, postpartum hemorrhage requiring transfusion, and cholecystectomy. She was not on any medications. She began experiencing daily rigors one week after her arrival, often accompanied by drenching sweats, and she lost approximately 5 kg of weight. She had intermittent midthoracic back pain, but no other localizing symptoms. Painful vaginal sores and dysuria developed one week later. She presented to the emergency room, where she was diagnosed with genital herpes simplex and secondary bacterial infection. She was prescribed a one-week course of cephalexin and one dose of azithromycin, but she continued to have rigors. One week later, she developed intermittent epigastric pain with no nausea, vomiting or diarrhea. She returned to the emergency room with a fever of 39.5°C, and was admitted for presumed pelvic inflammatory disease. She was treated with various broad-spectrum antibiotics and acyclovir but remained persistently febrile. All cultures were negative and her pelvic ultrasound was unremarkable. She was transferred to a tertiary care hospital one week later for consultation with an infectious disease specialist. Further questioning revealed that she was from a city in Mexico where she lived in close proximity to chickens. She denied having recent insect bites, sick contacts, intravenous drug use and tattoos. She had two previous male sexual contacts, including her husband, who she said had died at 27 years of age from lung cancer. On examination, she was hemodynamically stable and slightly tachypneic, with a temperature of 38.4°C and an oxygen saturation of 96% on room air. Her head and neck examinations revealed two small umbilicated papules on the right upper eyelid and white lesions on the tongue and buccal mucosa. There was no lymphadenopathy. Her cardiovascular, respiratory, abdominal and neurological examinations were unremarkable. Blood tests on admission were significant for the following: hemoglobin of 90 g/L with a mean corpuscular volume of 75.8 fL, white blood cell count of 3.1×109/L (2.9×109/L neutrophils and 0.2×109/L lymphocytes), aspartate amino-transferase level of 132 U/L, alanine aminotransferase level of 28 U/L, alkaline phosphatase level of 386 U/L, bilirubin level of 6 μmol/L and lactate dehydrogenase level of 1283 U/L. Her chest x-ray showed a diffuse reticulonodular pattern. Diagnostic tests were performed.

Keratoacanthomas associated with sorafenib therapy

Sorafenib inhibits several tyrosine and serine/threonine kinases (vascular endothelial growth factor (VEGF) receptor 2 and 3, platelet derived growth factor (PDGF) receptor B-Raf, Raf-1, Flt3, c-kit, β, and RET).2,3 Common sorafenib toxicities include diarrhea, hypertension, fatigue, and cutaneous lesions (facial and scalp erythema, focal acral erythema/acral erythrodysesthesia/hand-foot syndrome, alopecia, and splinter hemorrhages).

The development of oral lesions in lambs naturally infected with orf virus

Stomatitis in sheep caused by orf virus can be confused with lesions of more economically significant diseases, including foot-and-mouth disease, but there is no published account of the sequential development of oral orf lesions in the sheep. This report describes the clinical appearance of such lesions during a natural outbreak of the disease in young lambs. Lesions were seen on the gingiva, the tongue and the dental pad/hard palate, and progressed from small erythematous papules to larger, often coalescing papules that in some cases were ulcerated. Resolution started within seven days and was complete within 22 days. The lambs continued to suck and thrive throughout the infection. Lesions at all stages were proliferative, providing a major differentiating factor between orf and other causes of stomatitis in sheep.

Seasonal allergic dermatitis in sheep in southern Brazil caused by Culicoides insignis (Diptera: Ceratopogonidae)

The incidence of seasonal dermatitis was studied in a Hampshire Down flock on a farm in southern Brazil. Epidemiological data, clinical signs and macroscopic pathology were obtained by visiting the farm. Histological lesions were studied in skin biopsies of affected sheep. Biting insects were collected from January to April 2005 in an attempt to identify the etiological agent of the disease. Disease prevalence was 40%; the age of the affected animals was variable. Disease occurred from December to March, some animals had lesions for the entire year. Clinical signs include pruritus on the ears, around the eyes and ventral abdomen. Initially erythema and small red papules were seen, followed by alopecia and crust formation. Histologically the lesions were characterized by perivascular eosinophilic dermatitis. Hyperkeratosis and acanthosis were observed in the chronic lesions. Both Anopheles albitarsis and Culicoides insignis were captured during the study. C. insignis bites caused pruritus in sheep. Both types of insects were caught when they approached the sheep baits approximately 30 min after sunset. Results suggested that the disease occurred as a result of an immediate hypersensitivity reaction to C. insignis.

Immunoblot analysis of IgG antibody response to Sarcoptes scabiei in swine

This study was performed to determine the frequencies and specificities of IgG antibodies binding to component of Sarcoptes scabiei extracts in swine with hypersensitive and chronic mange. The hypersensitive form is characterised by pruritus and the presence of small red papules over the flanks and belly. The chronic form is characterised by crusts, which contain large numbers of mites and are attached to the skin; the lesions are most commonly found on the internal pinna extending into the auditory canal. S. scabiei mite extract was separated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis with subsequent immunoblotting. IgG-binding proteins were detected with individual sera from 30 hypersensitive and 21 chronically infected pigs; eight “Specific Pathogen Free” pigs were used as negative controls. Seven protein bands with molecular weights ranging from >220 to 30 Kilodalton (KDD) (>220, 218, 110, 80, 66, 52, 36 KDD) strongly bound with IgG antibodies; five out of these seven components (218, 110, 80, 66, 52 KDD) bound also with sera from negative pigs. There is a statistically significant difference in the antigenic recognition spectra between hypersensitive and chronically infected pigs; component of >220 KDD is more frequently recognized by chronically infected pigs ( P = 0.0006, χ 2 = 11.74), in contrast component of 36 KDD is more frequently recognized by hypersensitive pigs ( P = 0.001, χ 2 = 10). Our results clearly indicate there is a difference in the reactivity to antigenic peptides/proteins of S. scabiei mite between hypersensitive and chronically infected pigs, and revealed that only two antigens may be considered S. scabiei-specific and used for diagnostic purposes in swine.

Benign lymphangiomatous papules of the skin associated with ovarian fibroma

Benign lymphangiomatous papules of the skin are considered reactive lymphatic proliferations either caused by disruption of the lymphatic flow or tissue damage produced by operation or radiation therapy. We report a 72-year-old woman with umbilical papules and vesicle-like lesions that led to the diagnosis of a large ovarian fibroma. Histologic study revealed dilated lymphatic spaces manifesting an anastomosing and branched pattern in the papillary and reticular dermis dissecting collagen bundles. The vessels were lined by plump endothelial cells with foci of intravascular papillary endothelial cell hyperplasia. After the ovarian fibroma was removed by laparotomy, umbilical lesions almost disappeared, leaving small flesh-colored papules. A periumbilical dermatosis may herald certain intra-abdominal diseases including those of neoplastic derivation. A heightened awareness of this association may lead to an early diagnosis with a potential for improved patient outcome. Benign lymphangiomatous papules have not been previously described in association with an untreated tumor, without previous operation or radiotherapy. This case advocates for disruption of the lymphatic drainage as the probable pathogenetic mechanism.

PROLIFERATIVE DERMATITIS ASSOCIATED WITH A NOVEL ALPHAHERPESVIRUS IN AN ATLANTIC BOTTLENOSE DOLPHIN (TURSIOPS TRUNCATUS)

Herpesviruses and herpes-like viruses have been reported in only a small number of species of cetaceans, and, to date, clinical manifestations have been either as a life-threatening, disseminated infection or as a non-life-threatening dermatitis. A stranded juvenile Atlantic bottlenose dolphin, Tursiops truncatus, was admitted to the Dolphin and Whale Hospital for rehabilitation. On initial physical examination, the rostral skin had multifocal regions of hyperplasia, and the skin of the dorsum contained a large number of small papules. Histologically, epithelial hyperplasia was evident, and clusters of epithelial cells contained 5-15-microm intranuclear inclusion bodies. Transmission electron microscopic investigation revealed numerous 170-190-nm enveloped virions in both the intracellular spaces and the cytoplasm of epithelial cells, with numerous nucleocapsids noted in epithelial cell nuclei. Consensus primer polymerase chain reaction identified the presence of a novel herpesvirus associated with the lesions. Phylogenetic analysis of the deduced amino acid sequences of the herpesvirus DNA polymerase gene fragment showed it to align with alphaherpesvirus sequences from humans and domestic animals. Although clearly distinct, it was most closely related to two previously described alphaherpesviruses of dolphins. This case represents the first documentation of herpesvirus dermatitis in the Atlantic bottlenose dolphin.

Mixed-Type Neurothekeoma Presenting with an Unusual Clinical Appearance of Multiple Satellite Lesions on the Back

Neurothekeoma is a rare cutaneous neoplasm, often occurring as a nondescript cutaneous nodule on the central face, shoulders, and upper extremities. To present a patient with mixed-type neurothekeoma with an unusual clinical presentation. We report a 29-year-old female who developed an asymptomatic, red, dermal nodule with satellite papules on the back over a period of 6 months. The coalescing papules on the back were excised, and the histopathology and immunohistochemical study revealed a mixed-type neurothekeoma. Neurothekeoma usually presents with a small, solitary, and slow-growing nodule or papule on the upper body. The case is interesting because of the unusual clinical manifestation of one dermal tumor with several satellite lesions.

Nodular Skin Lesion in a Returning Traveler

As tropical countries become common travelers' destinations, more and more returning travelers are expected to present with cutaneous lesions secondary to myiasis. The skin lesion starts as a small red papule and gradually enlarges to become a furuncle. Familiarity with the characteristic clinical presentation and proper management would avoid an unnecessary diagnostic work-up and therapeutic intervention, including surgery and the use of antibiotics.

Acquired smooth muscle hamartoma

Smooth muscle hamartoma is an uncommon, usually congenital, cutaneous hyperplasia of the arrectores pilorum muscles. When it is acquired, it may be confused with Becker's nevus. We report a case of this rare tumor in a 19-year-old man. The disease started several years ago as multiple small skin-colored papules that subsequently coalesced to form a large soft plaque on the back of the left shoulder. The diagnosis of acquired smooth muscle hamartoma was confirmed on histopathology. The patient was reassured about the benign nature of the lesion and was not advised any treatment.

Scabies presenting with bullous pemphigoid-like lesions

A wide range of clinical manifestations may be seen in scabies, from classic pruritic papules and burrows to secondary features such as impetigo. Bullus lesions are a less frequent. Twenty cases of scabies presenting with bullae have been reported so far in the medical literature. Differentiating this subtype of scabies from the immunobullous disease bullus pemphigoid is a diagnostic challenge. A 42-year-old man was referred to our dermatology outpatient clinic with 3-month history of severe pruritus and tense blisters affecting mainly the lower trunk, arms and legs. An initial biopsy was suggestive for bullous pemphigoid. Close physical examination revealed small excoriated papules and a few burrows on borders of the hands and wrists. Skin scraping of the lesions on wrists was positive for Sarcoptes scabiei. Another biopsy specimen from a recent blister revealed subepidermal bullae with fibrin and inflammatory cells, particularly eosinophils. Direct immunofluorescence exam was negative. The patient was treated with lindane lotion followed by crotamiton cream with near complete resolution of the lesions. Scabies must be considered in patients presenting with recent onset of unexplained pruritic bullous lesions. Biopsy and immunofluorescence studies together with skin scrapings for Sarcoptes scabiei could help to differentiate these cases from bullous pemphigoid. Antiscabietic treatment results in resolution of bullous lesions in the affected patients.

Oral focal epithelial hyperplasia: report of five cases

Focal epithelial hyperplasia or Heck's disease is a rare contagious disease caused by human papillomavirus types 13 or 32, initially described among Native American populations. This condition is characterized by the occurrence of multiple small papules or nodules in oral cavity, especially on labial and buccal mucosa and tongue. This report describes the diagnosis of focal epithelial hyperplasia in five Central Amazonian Indians who sought treatment at the Amazonas State Foundation of Tropical Medicine (FMT-AM), using clinical criteria, polymerase chain reaction (PCR) and DNA sequencing.

A novel type of human papillomavirus (HPV 95): comparison with infections of closely related human papillomavirus types

Conflicts of interest: none declared. Sir, Infection with certain human papillomavirus (HPV) types induces warts with specific macroscopic and microscopic features.1 Clinical, histological and virological correlations have been established between myrmecia (deep palmoplantar warts), granular intracytoplasmic inclusion bodies (Gr‐ICBs) and HPV 1, between pigmented warts, homogeneous (Hg)‐ICBs and the related HPV 4, 60 and 65, and between punctate warts, filamentous (Fl)‐ICBs and HPV 63. We recently observed a distinct type of Hg‐ICB in small wart‐like lesions in a 16‐year‐old Japanese renal transplant recipient with a 2‐year history of viral warts on her hands and feet (Fig. 1a). The asymptomatic small warty papules of normal skin colour shared some resemblance to those of HPV 2/27/57‐induced common warts, HPV 4/60/65‐induced pigmented warts, or HPV 88‐associated small wart‐like lesions.2 Microscopically, the epidermis was acanthotic with hyperkeratosis and partial hypergranulosis, with basic histological features compatible with those of common warts. The additional histological feature of eosinophilic Hg‐ICBs surrounding a vacuolated nucleus in each cell in the granular and upper spinous cell layers was characteristic for all lesions examined (Figs 1b,c). These microscopic features of the Hg‐ICBs resembled those of HPV 4/65‐associated Hg‐ICBs (Figs 1d,e) to a certain extent, but were quite distinct from those of HPV 60‐associated Hg‐ICBs (Fig. 1f), as well as those of HPV 1‐associated Gr‐ICBs, HPV 63‐associated Fl‐ICBs and HPV 88‐associated fibrillar ICBs. The subsequent comparative analysis of lesions displaying the different types of Hg‐ICB revealed an abundance of the HPV 95‐associated Hg‐ICBs in the upper epidermal cell layers, similar to that seen in HPV 4/65‐associated lesions, in contrast to a few scattered cells in the HPV 60‐infected lesions. HPV 95‐associated Hg‐ICBs shared the feature of eosinophilic bodies with a crescent‐like appearance with HPV 4/65‐associated Hg‐ICBs, in contrast to the round bodies in HPV 60‐associated Hg‐ICBs. The crescent‐like eosinophilic bodies were, however, usually ‘atrophic’ and separated from an extremely vacuolated nucleus in HPV 4‐induced warts, in contrast to that seen in HPV 65/95‐induced warts where they filled out the entire cytoplasm and encased the nucleus. Tiny vesicular structures seen within HPV 4/65‐associated Hg‐ICBs were not seen in Hg‐ICBs associated with HPV 95. Clear distinction between the different types of Hg‐ICB was not always possible, despite the differences mentioned.

Benign cutaneous Degos disease

A 24-year-old woman presented with an 8-year history of a recurrent asymptomatic rash characterized by small erythematous papules which evolved to form atrophic porcelain white scars with a telangectatic rim. She had never had gastrointestinal or neurological symptoms. A short trial of aspirin did not alter the behavior of the disease. Histology confirmed the clinical diagnosis of Degos disease. Degos disease is a rare disorder that has been classified into the benign or malignant variety. The malignant type has a poor prognosis. Gastrointestinal involvement is the most frequent cause of death. The existence of patients with a prolonged, purely cutaneous or benign form has been increasingly recognized. It may be impossible to classify a patient at the time of initial presentation. Her progress is consistent with the benign form.

Juvenile hyaline fibromatosis: a case report

Juvenile hyaline fibromatosis ( JHF ) is a rare autosomal recessive disease characterized by papulonodular skin lesions, gingival hyperplasia, joint contractures, and bone lesions. The skin lesions may consist of multiple large tumors, commonly on the scalp and around the neck, and small pearly, pink papules and plaques on the trunk, chin, ears, and around the nostrils. Here, we report a 2-year-old boy with characteristic stiffness of the knees and elbows and pink confluent papules on the paranasal folds, and periauricular and perianal regions. He also had hard nodules all over the scalp and around the mouth, and severe gingival hyperplasia. The lesions were totally excised and clinicopathological diagnosis was JHF.

Generalized eruptive histiocytoma with rapid progression and resolution following exanthema subitum

Generalized eruptive histiocytoma (GEH), which was first described by Winkelmann and Muller in 1963,1 is a rare, benign, self‐healing, non‐Langerhans' cell (LC) histiocytosis, clinically characterized by brownish to reddish, multiple small papules with central depressions, which are symmetrically distributed on the whole body and sometimes on mucosa.1 The eruptions disappear or resolve spontaneously and leave brown scars. We present an infant case of GEH with rapid progression and resolution following exanthem subitum (roseola infantum). A 14‐month‐old Japanese girl had a high fever lasting approximately 3 days, followed by faint erythematous macules on the trunk and extremities. Her paediatrician diagnosed exanthem subitum. Two weeks after she had recovered from her exanthem, she presented to our hospital with a complaint of numerous, small, asymptomatic skin‐coloured to slightly erythematous papules with central depressions on the trunk and extremities (Fig. 1). There were no eruptions on the mucous membranes. She was otherwise healthy clinically and investigations were normal. Serology revealed circulating IgG antibody against human herpes virus type 6, consistent with previous exanthem subitum. Histology revealed infiltrates of histiocytes intermingled with lymphocytes and a few multinucleated giant cells in the papillary and reticular dermis (Fig. 2). Immunohistochemical study revealed that the histiocytes expressed CD68, a macrophage marker, but not S‐100 or CD1a, both of which are markers of LCs. Electron microscopy revealed that the histiocytes had intracytoplasmic lysosomal structures reminiscent of eyeball‐like bodies, but no Birbeck granules (Fig. 3). We made a diagnosis of GEH. The eruptions resolved rapidly in about 1 month without any therapy. There has been no recurrence during 10 months of follow‐up after resolution of the eruptions.

Zinc paste bandages and the treatment of Flegel’s disease

Such is their prevalence in the population that community nurses are very likely to encounter unfamiliar dermatological problems during their practice, many of which will have been self-treated for some time before professional help is sought. This article reports a case of a rare congenital condition called Flegel's disease, which leads to the presence of small horny papules on the skin, predominantly on the legs. In this case, the papules had deteriorated and were causing wider problems.

Penicillamine induced pseudoxanthoma elasticum with elastosis perforans serpiginosa

Long term D-penicillamine therapy, especially when used to treat Wilson's disease has been shown to cause elastosis perforans serpiginosa, pseudoxanthoma elasticum perforans and other degenerative dermatoses. We report a 23-year-old male patient who presented with multiple firm papules, nodules over the neck, axillae, front of elbows for five years. He was a known case of Wilson's disease on long-term treatment with penicillamine for the past 12 years. The papulonodular lesions were non-tender and some were discrete while others were arranged in a circinate pattern. There was central scarring of the skin within the circinate lesions. In addition, there were several small yellowish papules on both sides of the neck which eventually became confluent to form plaques. Histopathology confirmed the diagnosis of elastosis perforans serpiginosa and pseudoxanthoma elasticum. He was treated with cryotherapy (using liquid nitrogen through cryojet) for former lesions. The lesions showed remarkable improvement after five sittings. Now the patient is under trientine hydrochloride (750 mg twice daily) for Wilson's disease.