Tender Nodules Research Articles

Deep Fungal Infections of Skin and Role of Histopathology in Diagnosis

Abstract Introduction: Deep mycoses acquired by penetrating trauma to the skin can have varied and sometimes atypical morphological presentations resulting in diagnostic dilemmas and delay in treatment onset. Histopathology can be a useful tool in not only diagnosing but also differentiating various deep mycoses. Aims and Objectives: To observe various morphological presentations and histopathological features of deep fungal infections. Materials and Methods: A retrospective multi-centric study was conducted from 2010 to 2020 at 16 centres. The cases with diagnoses of various deep mycoses were included in the study. The patients presenting with cutaneous manifestations were included in the study. Their demographic details, history, presenting signs and symptoms, morphological presentations, histopathological features and treatment details were collected from the case sheets. Results: A total of 124 cases were found from the case records. The most common type was chromoblastomycosis (42) followed by mycetoma (28) and rhinosporidiosis (17). The mean age was 43.76 ± 5.44 years. The average duration of symptoms before presentation was between 2 months to 10 years (average 2.5 ± 1.33 years). Male to female ratio was 1:0.7. Prior history of trauma was recorded in 36% of cases. Chromoblastomycosis cases presented with verrucous to atrophic plaques with black dots on the surface and histopathology findings included pesudoepitheliomatous hyperplasia, epithelioid cell granulomas, copper penny bodies within granulomas and abscesses. Rhinosporidiosis cases had polypoid grape-like lesions in the nose and eyes most commonly with histopathology findings of abundant thick-walled sporangia in dermis packed with thousands of spores. Eumycetoma patients had pigmented, indurated swelling with multiple sinuses discharging black granules and histopathology showed dermal abscesses and foreign body granulomatous reaction with PAS-positive hyphae. Histoplasmosis patients presented with few to multiple nodulo-pustular lesions on skin and palatal ulcers while small basophilic bodies packed in the cytoplasm of histiocytes were noted in histopathology. Phaeohyphomycosis cases presented as deep-seated cystic lesions and biopsy revealed deepithelialized cysts in the dermis or hypodermis with lumen showing necro inflammatory debris and fungal hyphae. Sporotrichosis cases had erythematous, tender nodules and papules either as single lesions or as multiple lesions arranged in a linear fashion and histopathology showed pseudoepitheliomatous hyperplasia of epidermis, loose to well-defined epithelioid cell granulomas and microabscesses. Spores were found in two cases. Cryptococcosis patient had multiple umbilicated lesions resembling giant molluscum contagiosum loose epithelioid cell granulomas and medium-sized spores lying in both intra and extracellularly on histopathology. Penicilliosis patients had nodulo-pustular lesions and histopathology showed an admixture of histiocytes, epithelioid cells, plasma cells, lymphocytes and polymorphs in the dermis with the presence of yeast-like spores in the cytoplasm of histiocytes and epithelioid cells. Entomophthoromycosis cases presented with asymptomatic subcutaneous firm swelling with loss of skin pinchability. Conclusion: Though clinical findings of deep fungal infections are characteristic similar morphology and atypical presentations can be sometimes confusing. Histopathology is useful for confirming the diagnosis.

Tender nodules on the sole of the foot

Tender nodules on the sole of the foot

Coalescing Tender Nodules on the Anterior Chest: An Atypical Presentation of Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is an inflammatory skin condition that is characterized by inflamed nodules and abscesses that can form sinus tracts under the skin, typically in skin fold areas, that are tender and drain pus. Efficient diagnosis and early intervention is critical for this condition, as initiating treatment can keep the lesions under control and prevent worsening of nodules that can cause significant discomfort and permanent scarring. Here, we present a case of an unusual presentation of hidradenitis suppurativa in a 41-year-old male who presented to the emergency department with a chief complaint of a tender, purulent anterior chest cutaneous mass, which pathology later confirmed was consistent with an HS lesion. While HS typically occurs in regions with skin folds, this case illuminates an atypical presenting area – the anterior chest wall. Thus, clinicians should keep HS on the differential for such lesions, as the location of the affected area should not rule in or out HS as a diagnosis.

Case report: Perineal swelling: A rare case of scar endometriosis.

We report a rare case of episiotomy site scar endometriosis manifested as painful perineal swelling near the anus for 2 years affecting daily routine activity, especially during menses. A 33-year-old female, para 2 with both vaginal deliveries with last child birth 8 years back. A 2.5 × 3 cm firm, tender nodule was present on the posterior vulva at the right mediolateral episiotomy site. Trans-perineal and trans-anal ultrasound scan was done, anal sphincter involvement was ruled out and the nodule was excised with free margins. histopathology confirmed the diagnosis of scar endometriosis. The key takeaway from this case is endometriosis can present after 8 years of vaginal delivery. The timely diagnosis and treatment is necessary as delay may cause anal sphincter involvement or malignant transformation.

Unusual Presentation of Marginal Zone Lymphoma

Primary cutaneous B-cell lymphomas (pcBCLs) are non-Hodgkin lymphomas that present with exclusive cutaneous disease at the time of diagnosis. The lesions may be indolent, subtle, or waxing and waning, making the diagnosis challenging. The ear is an uncommon location, and its frequency of involvement remains unknown. A retrospective analysis of a single patient with primary cutaneous marginal zone lymphoma of the ear. The patient was a 44-year-old male who presented with erythematous tender nodules on the left superior posterior helix. Shave biopsy revealed mixed dermal lymphoid infiltrate with eosinophils and telangiectasias. The patient was diagnosed with angiolymphoid hyperplasia with eosinophilia. Multiple treatment regiments were trialed but failed due to lack of therapeutic response, relapse, and clinical progression. The patient ultimately underwent Mohs surgery with biopsy findings that demonstrated CD-20 positive cells. Evaluation with B-cell histopathology and gene rearrangement studies confirmed the diagnosis of marginal zone lymphoma. This case report shows a unique presentation of marginal zone lymphoma of the ear, initially diagnosed as angiolymphoid hyperplasia with eosinophilia. Our findings demonstrate a relatively rare presentation for this disease and highlight the challenges in diagnosing primary cutaneous marginal zone lymphoma.

A Delayed Diagnosis of Bilateral Pediatric Trigger Thumbs: A Case Report and Literature Review

We describe the case of a 6-year-old female who presented with tender nodules and fixed flexion of her thumbs, diagnosed as bilateral pediatric trigger thumb. Though present since infancy, her condition was not diagnosed in prior clinical visits. Pediatric trigger digit is a clinical diagnosis, often missed if the digit's range of motion is not assessed routinely. Given the duration, pain, and severity of her condition, conservative management was deferred, and she was referred for surgery. An approach to clinical management is discussed. Ultimately, further study is required to develop structured management guidelines for pediatric trigger digit.

Mycobacterium welchii Vaccine Granuloma – A Cautionary Tale

Background: Mycobacterium welchii (Mycobacterium w) vaccine was one of the many strategies used to both treat and prevent coronavirus disease 2019 (COVID-19) infection. We report the results of a retrospective analysis of 15 cases with vaccine-site granulomas after administration of prophylactic Mycobacterium w vaccine as part of a trial for COVID-19 and our experience in managing those cases. Methods: This was a retrospective analysis of 15 patients with vaccine-site granulomas who were given the vaccine as a prophylactic measure as part of a trial with informed consent. Results: The mean average age of cases was 37 and the male-to-female ratio was 1:0.87. All of the patients developed erythematous tender nodules over the injection sites within a month of receiving the inoculations. Mycobacterial cultures and cartridge-based nucleic acid amplification tests yielded negative results. Skin biopsy revealed granulomatous dermatitis with acid-fast bacilli positivity. A diagnosis of noninfective granulomatous dermatitis was made. Treatment started with analgesics and anti-inflammatory agents. Systemic antibiotics were required in 9/15 patients. Patients are being followed up with no reported recurrence till date. Conclusion: The possibility of injection-site granuloma should be taken into the risk–benefit analysis for the administration of Mycobacterium w vaccine and the patients should be counseled as such. Patients with persistent ulceration respond to combinations of doxycycline, ofloxacin, and clarithromycin.

Low-grade extrauterine endometrial stromal sarcoma arising from vaginal endometriosis: a case report and literature review.

Extrauterine endometrial stromal sarcoma arising from malignant transformation of the vagina is an extremely rare condition. The diagnosis is often difficult as the symptomatology and pathological features overlap with that of pelvic endometriosis. A 38 years old female presented with complaints of dyspareunia, dysmenorrhea, and painful defecation along with blood-stained vaginal discharge for a year. Examination revealed the presence of multiple brownish irregular nodules in posterior vaginal fornix and fixed tender nodules which on biopsy revealed florid vaginal endometriosis. She improved symptomatically on medical therapy. After 18 months of diagnosis, she presented again with a necrotic growth in posterior fornix, which on repeat biopsy revealed a low-grade endometrial stromal sarcoma. Laparotomy revealed a 7×5 cm mass in the pouch of Douglas, infiltrating the posterior vaginal wall and rectum. A complete cytoreductive surgery with retrograde hysterectomy, excision of posterior vaginal wall and rectosigmoid resection was done. The patient is disease-free at a follow-up of 65 months.

SQUIZ your knowledge: Tender nodules of the hands in a patient with cutaneous lupus erythematosus.

sQUIZ your knowledge: Tender nodules of the hands in a patient with cutaneous lupus erythematosus.

Leiomyoma of the Ankle

Leiomyomas, also known as fibroids, are benign tumors originating from smooth muscle and can arise in soft tissue, most commonly in the uterus or bladder. Those that arise in the extremities usually form subcutaneous masses. Leiomyoma of the foot has rarely been reported, and leiomyoma of the ankle is even rarer. A 52-year-old male presented with a tender nodule on the lateral aspect of his right ankle. The tumor was surgically excised and was shown to be a leiomyoma.

Coronavirus disease 2019 pandemic related chondrodermatitis nodularis helicis: the role of masks.

Chondrodermatitis nodularis helicis is a benign, but painful inflammatory condition of the ear, characterised by a tender nodule located on the helix or antihelix. This study aimed to investigate the occurrence of chondrodermatitis nodularis helicis associated with the use of coronavirus disease 2019 masks during the pandemic. A retrospective single-centre study was performed from February 2020 to February 2022 in the Maxillo-Facial Unit at the University Hospital of Siena, Italy. During the indexed period, 11 patients were affected by chondrodermatitis nodularis helicis. All patients wore a mask for more than 8 hours a day, every day for several months. Although there is no certain proof of the correlation between masks and chondrodermatitis nodularis helicis, an increase in the incidence of this condition was highlighted in our single-centre experience in the pandemic period. The prolonged use of coronavirus disease 2019 masks may explain this correlation.

Erythema nodosum A rare inflammatory disorder

Erythema nodosum is a rare inflammatory disorder that affects the subcutaneous fat layer. We present a case of a 32-yearold male patient who presented with painful nodules on his lower legs, associated with mild fever, malaise, and joint pain. Laboratory tests, including a complete blood count, comprehensive metabolic panel, and C-reactive protein, were within normal limits. A skin biopsy confirmed the diagnosis of erythema nodosum. The patient was started on a course of nonsteroidal anti-inflammatory drugs, and the nodules resolved over several weeks. This case highlights the importance of considering erythema nodosum in the differential diagnosis of a patient presenting with tender nodules on the lower legs and underscores the need for appropriate investigation to identify any underlying systemic cause

P01 Severe adult-onset inflammatory disorder with associated UBA1 somatic mutation

Abstract A 70-year-old man was admitted to the hospital with a 2-week history of fatigue, florid erythematous maculopapular rash, elevated inflammatory markers and thrombocytopenia. A skin biopsy was performed that showed features in keeping with Sweet syndrome, which was initially thought to relate to concurrent gastrointestinal sepsis. The patient was commenced on oral prednisolone 30 mg daily. His rash and inflammatory markers improved, but his ferritin levels remained elevated. Within 1 month, he presented again with a widespread rash comprising tender and erythematous nodules. Serial computed tomography did not reveal an underlying malignancy. The patient was referred to haematology for consideration of a bone marrow biopsy, which showed hypercellular marrow with active trilineage haematopoiesis, and dysplastic changes in granulocytes and megakaryocytes. Molecular analysis showed a characteristic UBA1 p.(Met41Leu) mutation, which confirmed a diagnosis of VEXAS syndrome. He was considered for treatment with tocilizumab, but his skin symptoms responded well initially to oral steroids and, later, dapsone. He remains asymptomatic on dapsone. VEXAS syndrome is an autoinflammatory condition, first described in 2020, that results in a constellation of inflammatory and haematological manifestations due to a somatic mutation in UBA1 on the X chromosome. It can affect the skin, cartilaginous structures, lungs, joints and vasculature, as well as the haematopoietic cells. Patients with this condition have only been partially responsive to treatment, with high doses of corticosteroids showing the most consistent benefit of all the modalities tried thus far. The prognosis is poor and diagnosis is usually delayed. To date, relatively little is known about the dermatological manifestations of VEXAS syndrome. These are usually characterized by neutrophilic dermatoses or vasculitis. More recent studies have shown that skin involvement is associated with clonal infiltration of the skin rather than a general proinflammatory activation. This suggests that therapies that target the pathological clone, as well as the proinflammatory milieu, such as steroids and Janus kinase inhibitors, may be useful. However, further studies and trials are required to understand how to best cure the disease.

(087) Why Should Pelvic Floor Physical Therapy be Included in Treatment of Vestibulodynia?

Abstract Introduction Vestibulodynia, vulvar pain localized to the vestibule without an identifiable cause, has a multifactorial etiology including neurologic, hormonal, inflammatory, psychologic, and musculoskeletal factors. Key pathophysiologic drivers likely vary from patient to patient. Published studies demonstrate that compared to controls, patients with provoked vestibulodynia are more likely to have pelvic floor hypertonicity and decreased pelvic floor strength, as measured by dynamometric speculum and ultrasound. Further, observational studies describe improvement of vestibulodynia symptoms with pelvic floor physical therapy, suggesting a causal relationship between pelvic floor hypertonicity and vestibulodynia. Objective To describe the pathophysiologic mechanism by which pelvic floor dysfunction and myofascial trigger point development could cause vestibuoldynia, with a focus on pelvic floor anatomy. Methods Literature about vestibulodynia, pelvic floor dysfunction, and pelvic floor anatomy was reviewed and synthesized in conjunction with expert clinical experience of pelvic floor physical therapists and gynecologists. Results The pelvic floor consists of the levator ani muscles (iliococcygeus, pubococcygeus, and puborectalis) and ischiococcygeus, which form a basket to support the pelvic organs. The puborectalis inserts in the posterior vestibule, and hypertonicity can cause allodynia in this region. The levator ani are innervated by the levator ani nerve, which originates from S3-S5 and traverses the visceral surface of the muscles. Some cadaveric studies suggest dual innervation of the levator ani by the pudendal nerve, which originates from S2-S4 and courses over the inferior surface of the muscles. Pelvic floor hypertonicity, increased resting tone of the pelvic floor muscles, can result from many factors including stress, bladder and rectum voiding habits, and painful pelvic processes (i.e. interstitial cystitis, endometriosis). Increased muscle tone can promote sensitization of muscle afferent fibers and neuropathic upregulation. This may be perceived as vestibulodynia because the vestibule contains visceral and somatic sensory nerve fibers, whose signals are integrated at the same spinal levels as those from the levator ani. This anatomy allows for somatovisceral convergence of afferent signals, and thus perception of vestibular pain. Hypertonicity of the pelvic floor muscles decreases circulation creating localized hypoxia that can promote development of myofascial trigger points (tender nodules) in the pelvic floor. These trigger points can cause allodynia, perceived in the vestibule. In some cases, vestibulodynia may develop first and promote pelvic floor hypertonicity. Conclusions As pelvic floor hypertonicity can contribute to the pathogenesis of vestibulodynia, it is imperative for clinicians to include pelvic floor tone evaluation in their assessment of vestibulodynia. If pelvic floor hypertonicity is present, it should be treated concurrently with vestibular pain through a combination of pelvic floor physical therapy, trigger point injections, and botulinum toxin injections as pelvic floor hypertonicity and vestibulodynia may each perpetuate the other. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Johnson & Johnson.

(152) A Case of Penile Neoplasm Masquerading as Acute Peyronie's Disease

Abstract Introduction Painful erections with curvature is pathognomonic for acute Peyronie’s Disease (PD). While resolution of pain and stabilization of curvature define the transition from acute to stable PD, there is high variability in the time from symptom onset to resolution. Thus, when to image and consider alternative diagnoses is poorly defined. We present a case of persistent distal penile pain and curvature with erections, initially diagnosed as acute PD, but subsequently found to be epithelioid hemangioendothelioma (EHE), a rare vascular neoplasm on the spectrum between a hemangioma and an angiosarcoma, with high probability of local recurrence and ability to metastasize. Objective To raise awareness that painful penile erections with curvature may not necessarily represent acute PD and foster discussion of when imaging, testing and alternative diagnoses should be considered. Methods Case report of a 51-year-old male seeking a third opinion for painful penile nodule with curvature of approximately four years duration. Results A 51-year-old male presented to our clinic complaining of an extremely painful penile nodule with curvature. He initially presented to another urologist with similar symptoms approximately 4 years previously and was diagnosed with acute PD. He had no prior history of penile trauma, erectile dysfunction, Dupuytren’s contractures or family history of PD. He was started on vitamin E, L-arginine and pentoxyphylline. He sought a second opinion about three years later when his symptoms remained unchanged and, again, was diagnosed with acute PD and told to return when his pain had resolved. His symptoms persisted and approximately 1 year later presented to our clinic for evaluation. Physical examination demonstrated a 1 cm tender nodule between the corpora cavernosa at the distal shaft. Pharmacologic erection demonstrated a 30-degree upward curvature at this site. Given the duration of his symptoms, ultrasound was obtained. A 1.4 cm circumscribed lesion with internal vascularity was identified; however, MRI identified dorsal angulation of the shaft in this area but did not visualize a mass. Due to extreme pain, the patient desired excision of the mass. Intraoperatively, a well circumscribed lesion with a vascular pedicle was identified between the corpora and the neurovascular bundle. The mass was easily excised without evidence of invasion of surrounding tissues. Final pathology demonstrated an epithelioid hemangioendothelioma with question of a positive margin. The case was discussed at a Multidisciplinary Tumor Board and given the sparsity of literature on the tumor, particularly in the penis, it was felt that excision of surrounding tissues to ensure negative margins would be best. The patient returned to the OR two weeks after his initial surgery and the surrounding corpora were excised. Final pathology demonstrated no evidence of residual malignancy. PET/CT was negative for metastatic disease. Conclusions While current guidelines indicate that penile angulation may rarely be due to other causes, including tumors, there are no recommendations on when alternative diagnoses should be investigated and imaging obtained. We present a case report of epithelioid hemangioendothelioma masquerading as acute PD that was identified due to abnormal duration of symptoms. Disclosure No

Recent-onset erythematous tender plaques and nodules in a child with nephrotic syndrome.

A 10-year-old girl with nephrotic syndrome who was on systemic corticosteroids presented with multiple erythematous tender nodules over her trunk and extremities. Histopathology showed mild lobular panniculitis with needle-shaped crystals. The lesions subsided spontaneously without any sequelae within 3 weeks.

COVID-19-Associated Erythema Nodosum Detected on FDG PET/CT.

We report the case of a 69-year-old woman who underwent 18F-FDG PET/CT due to prolonged fever. One month before, the patient was diagnosed with COVID-19 infection. The 18F-FDG PET/CT showed several subcutaneous nodules with 18F-FDG uptake on the thorax and upper extremities and bilateral lung infiltrates due to organizing pneumonitis. Clinical examination revealed multiple tender nodules on thorax, arms, and legs, consistent with erythema nodosum (EN) induced by COVID-19 infection. The woman was treated with prednisone with a good effect on EN. To our knowledge, this is the first report on EN secondary to COVID-19 infection diagnosed on 18F-FDG PET/CT.

Perineal scar endometriosis

The presence of ectopic endometrial tissue outside the uterine cavity is referred to as endometriosis. It is a harmless condition that is commonly seen in women of reproductive age. It can happen in both the pelvic and extra-pelvic areas. Endometriosis in an episiotomy scar is extremely rare, but due to local infiltration, it can cause significant morbidity in patients. The presence of the classic clinical triad of episiotomy history, tender nodule at the scar site, and cyclical pain can be used to diagnose this condition. Magnetic resonance imaging is a very useful imaging modality for diagnosing and assessing the lesion’s deeper extent.

Approach to dysmenorrhoea in primary care.

Approach to dysmenorrhoea in primary care.

149 Sweet’s Syndrome: One Center Study of 42 Patients

Sweet’s syndrome (SS) is a rare acute febrile neutrophilic dermatosis characterized by an abrupt onset of fever, arthralgia, neutrophilia, tender erythematous papules, nodules, and plaques. We present a case series of patients seen at the dermatology department of the Ibn Sina University Hospital (Rabat). The goal of our study was to describe the epidemiological, clinical profile and the possible association of the Sweet syndrome in our department. We performed a descriptive retrospective study of 42 Moroccan patients seen between January 2004-January 2020.