Efstathios Rallis

Pimecrolimus induced tinea incognito masquerading as intertriginous psoriasis.

A 58‐year‐old, obese, male, army officer was presented with tinea incognito of the groin masking intertriginous psoriasis. According to his history, he had pruritic, symmetrical erythematous eruption of the groin of 2‐month duration that he treated himself by using topical pimecrolimus 1%. This medication had been prescribed for his 8‐year son’s atopic dermatitis by the paediatrician. Direct examination with potassium hydroxide preparation showed fungal hyphae and Trichophyton rubrum was isolated in culture. This is the second case of topical pimecrolimus induced tinea incognito. We also review the cutaneous disorders that tinea incognito may mimic.

Multiarticular chronic tophaceous gout with severe and multiple ulcerations: a case report

IntroductionGout is a common inflammatory arthritis caused by articular precipitation of monosodium urate crystals. It usually affects the first metatarsophalangeal joint of the foot and less commonly other joints, such as wrists, elbows, knees and ankles.Case presentationWe report the case of a 75-year-old Caucasian man with tophaceous multiarticular gout, soft-tissue involvement and ulcerated tophi on the first metatarsophalangeal joint of the left foot, on the first interphalangeal joint of the right foot and on the left thumb.ConclusionUlcers due to tophaceous gout are currently uncommon considering the positive effect of pharmaceutical treatment in controlling hyperuricemia. Surgical treatment is seldom required for gout and is usually reserved for cases of recurrent attacks with deformities, severe pain, infection and joint destruction.

Ustekinumab for the treatment of HIV psoriasis

Psoriasis is a common, chronic, immune-mediated inflammatory skin disease that may cause psychosocial comorbidities in affected population. The prevalence of psoriasis in HIV-infection is 1–2%, no higher than in the general population indicating that HIV may be not a trigger for this dermatosis but rather a modifying agent (1,2). A 61-year-old male, MSM (males who have sex with males), with HIV-infection and 35-year known history of plaque-psoriasis recalcitrant to highlyactive-antiretroviral-therapy (HAART), acitrecin, PUVA, methotrexate, cyclosporine, and etanercept (Table I) was referred to our department in October 2009. At the time of examination the disease was extensive affecting his scalp and trunk. His parameters were as follows: mean psoriasis area and severity index (PASI): 11.9, physician’s global assessment (PGA): 3, CD4: 429 cells/ml and viral load: <50 copies/ml. According to the family history his father and one of his three sisters also had psoriasis. The disease was affecting significantly his healthrelated-quality of life especially in exacerbationperiods thus he was advised to receive ustekinumab. His body weight was less than 100 kg. He underwent laboratory tests, chest x-ray and tuberculin test that were all within normal ranges. He received ustekinumab at a dose of 45 mg subcutaneously, at weeks 0, 4 and 16. He was evaluated at week 12 and presented good response with reduction of the PASI: 2.7 (overall improvement of 75.9%). He achieved PASI 90 at week 18. The patient is still under treatment with ustekinumab at a dose of 45 mg every 12 weeks. The drug was well-tolerated and no side effects were recorded. Favorable effects on CD4 counts were demonstrated during ustekinumab administration without impairment of viral suppression. After the second injection the patient’s CD4 count increased to 480 cells/ml and 7 months after ustekinumab initiation CD4 count was 530 cells/ml while viral loads remained undetectable below 20 copies/ml. The immune dysfunction resulting from HIV may be associated with several cutaneous disorders. Psoriasis might be suddenly presented after HIV infection or deteriorated in a patient with existing psoriasis, as in our case. It tends typically to worsen or to occur in late disease with advanced immunodeficiency (3). Antiretroviral therapy has been reported to improve psoriasis in the setting of HIV-infection with a parallel reduction of HIV-viral load (4). In our patient the administration of HAART decreased HIV-viral load (Table I) but proved ineffective to his psoriasis. There are no randomized placebo-controlled trials or treatment of choice for the management of moderate-to-severe HIV-psoriasis. Based on single cases anti-TNF-a agents including etanercept and infliximab have been used successfully and safely in HIV-associated psoriasis and psoriatic arthritis. Etanercept has also been reported to improve other symptoms associated with HIV (5).

Malignant fibrous histiocytoma masquerading as gluteal abscess.

To the Editor: Soft tissue sarcomas are rare tumors. They involve various types of connective tissue and account for approximately 1% of adult malignancies. Malignant fibrous histiocytoma (MFH) is a form of malignant sarcoma with a tendency to metastasize to distant areas of the body, especially the lungs. The treatment and outcome of this condition depend on the stage, type, and metastatic behavior of the tumor. We describe an interesting case of MFH that presented as a gluteal abscess. An 85-year-old female was referred to our department because of fever (39.4uC), erythema, and swelling of the left buttock. A clinical examination revealed a warm and painful abscess, 2 3 2 cm in diameter. Routine laboratory tests showed leukocytosis (17,000 mL), and anemia (hemoglobin 10.1 mg/dL). A chest radiograph, an abdominal sonogram, and urine and blood cultures were within normal ranges. The abscess was drained under local anesthesia, and surgical débridement was performed. Bacteriologic examination from the pus revealed the presence of Staphylococcus aureus, and according to the antibiogram, the patient was treated with doxycycline 100 mg twice daily for 10 days postoperatively. Forty-five days after the drainage, the patient was referred to the emergency department because of the rapid development of a sizable, friable, hemorrhagic mass arising from the site of the gluteal abscess that had been treated (Figure 1). Laboratory investigation revealed anemia (hemoglobin 8 mg/dL) and abnormal coagulation parameters (international normalized ratio 5). Axial contrastenhanced computed tomographic images demonstrated an increasingly hyperdense lesion. The center of the lesion was hypodense and probably necrotic, with irregular borders. The lesion was extending from the subcutaneous tissue, invading the adjacent gluteus maximus, gluteus medius, and piriformis muscles. Cytoreduction under epidural anesthesia was performed, and the resected specimen measured 17 3 15.5 3 4.5 cm in diameter. Histologic examination showed a variable morphologic pattern with storiform and pleomorphic areas. Storiform areas consisted of atypical spindle cells with medium or large irregular vesicular nuclei and prominent nucleoli. Pleomorphic areas contained plumper fibroblastic cells, with large vesicular clear nuclei and eosinophilic cytoplasm. Extensive necrosis was also present. Immunohistochemical stains revealed immunoreactivity for vimentin (Figure 2) and no reaction for pankeratin, desmin, HMB-45, smooth muscle actin, and S100. The histologic picture was compatible with MFH. Unfortunately, the patient died 15 days after the excision of the tumor because of pulmonary edema owing to chronic atrial fibrillation. Although the reason for the fatal outcome was unrelated to MFH, we believe that the delayed diagnosis of the tumor played a significant role in the patient’s poor condition. The incidence of MFH is estimated as 17% of soft tissue sarcomas, and the storiform-pleomorphic histologic variant represents 70% of MFH cases. Soft tissue sarcomas are usually asymptomatic, described as indolent, unmoveable masses. Rarely, they may mimic a hematoma or an abscess, and these uncommon presentations further delay diagnosis and treatment, as in our case. The development of an abscess has been commonly attributed to trauma, injection, or infection of underlying seborrheic cysts. Drainage of abscesses, often followed by débridement, is commonly performed under local anesthesia. Surgical excision of the lesion is the treatment of choice. Additional radiotherapy and/or chemotherapy should be individualized.

Pemphigus Vulgaris with Plaque-Type Psoriasis Successfully Treated with Cyclosporine Monotherapy

To the Editor: The coexistence of psoriasis vulgaris with an autoimmune blistering disease is well documented in the literature. Pemphigus-related disorders are less frequently described coexisting with psoriasis, and bullous pemphigoid is the most frequent autoimmune bullous disorder reported in association with psoriasis. Cyclosporine (ciclosporin) is utilized widely with good therapeutic outcome for the treatment of inflammatory skin diseases including psoriasis and bullous disorders. To our knowledge, we present the first case of coexistent plaque-type psoriasis and pemphigus vulgaris treated successfully with cyclosporine monotherapy. A 71-year-old woman was referred to our clinic in March 2007 because of the appearance of persistent, oral erosions of 5 months’ duration and extensive erosions and crusts on the trunk and back (figure 1a), first noticed 3–4 months before her admission. She also had typical psoriatic plaques on the scalp, back (figure 1b), elbows, knees, and the gluteal area of 10-year duration, and had received no treatment for this condition during the previous year. The rest of the personal medical history was significant for type 2 diabetes mellitus, partially controlled with metformin tablets. A 3mm punch biopsy was performed from the edge of a bullous lesion. Histologic examination revealed a suprabasilar blister with acantholysis (figure 2). Basal cells were separated from one another but they remained attached to the basement membrane.Direct immunofluorescence showed IgGdepositionon the surface of the keratinocytes. Indirect immunofluorescence revealed the presence of circulating IgGanti-keratinocyte cell surface antibodies at a titer of 1:160 in the patient’s serum. These findings were compatible with the diagnosis of pemphigus vulgaris. The patient did not consent to receiving an anti-tumor necrosis factor-a agent for both dermatoses and she was therefore treated with oral cyclosporine at a dosage of 300mg/day (3.5mg/kg). A very good improvement of both psoriasis and pemphigus lesions was noticed at the end of the second week of cyclosporine administration. After 35 days of cyclosporine treatment the patient presented with significant remission of both skin conditions (figure 3) and continued with the same dosage. We reviewed the patient regularly and, 3 months later, cyclosporine was gradually discontinued. No relapse was seen 5 weeks after the discontinuation of the medication. The patient subsequently relapsed during the third month after discontinuation of cyclosporine. Psoriasis vulgaris is the most prevalent T-cell-mediated inflammatory disease in humans. Pemphigus is an autoimmune, intraepithelial, blistering disorder that is mediated by circulating autoantibodies directed against keratinocyte cell surfaces. An attempt to establish a possible common pathogenesis of bullous disease and psoriasis has been made. In most cases, the bullous eruption has been thought to be related to antipsoriatic treatment; however, no such association was seen in our case.

Malignant syphilis as the first manifestation of HIV infection.

Malignant syphilis is a rare and severe variant of secondary syphilis. It is clinically characterized by large papular, nodular and ulcerative lesions affecting the trunk and the extremities and covered with thick crust. We present a case of 52-year-old homosexual male who developed malignant syphilis and this was the first clinical manifestation of HIV infection. The patient was treated successfully with intravenous aqueous crystalline penicillin G. Physicians should recognize malignant syphilis and consider it in all HIV-infected individuals with ulceronodular skin lesions.

Pigmented perianal macules

Primary mucosal melanoma occurs in under 2% of melanomas. Anorectal melanoma is a rare disorder, approximately accounting for 1% of all anorectal carcinomas. Primary anorectal melanoma presents predominantly in women, in the 4th–6th decade of life. Typical clinical manifestations include rectal bleeding and tenesmus. The prognosis remains poor.

Peripheral nerve sheath tumour mimicking thrombophlebitis

A 70-year-old male underwent an optical urethrotomy in 2010 for treatment of a dense 3-cm anastomotic urethral stricture. His history is significant for Gleason 9 T2b prostate cancer treated with an uncomplicated prostatectomy in 1998 and external beam radiotherapy in 2003 secondary to local recurrence. His urethral catheter was removed day 3 post-optical urethrotomy. He developed right groin pain radiating to the inner thigh and had difficulty weight bearing on the right leg over the subsequent days. His symptoms intermittently worsened and he presented 5 weeks post-optical urethrotomy to the emergency department with a fever, right groin pain and inability to walk. His C-reactive protein was elevated at 137 mg/L and a urine culture positive for pseudomonas aeruginosa. A contrast-enhanced computed tomography scan of his abdomen and pelvis revealed a hypoechoic lesion in his obturator externus muscle. An initial bone scan showed no area of increased uptake to suggest osteomyelitis. On day 3 of admission, a magnetic resonance imaging showed an extensive collection within the right obturator externus measuring 3.7 ¥ 2.1 cm as well as osteomyelitis of the pubis (Fig. 1). Ultrasound-guided drainage of the collection aspirated 3 mL of purulent material which grew Pseudomonas aeuroginosa. Optical urethrotomy is considered a safe and effective treatment for urethral strictures. The most common complications are fever, bleeding, urinary tract infection, epididymitis, urinary incontinence, urinary extravasation and recurrence of stricture. We postulate that a disruption of the anatomical planes secondary to radiotherapy resulted in the extravasation of urine, from a breach in the corpus spongiosum at time of urethrotomy, into the superficial perineal space which then tracked deep to Colles’ fascia into the medial compartment of the thigh. Pyomyositis is a rare but possible complication of optical urethrotomy, with patients previously treated with local radiotherapy at particular risk.

Microsporum canis tinea capitis in a centenarian patient.

Sir, Tinea capitis is a dermatophyte infection of the scalp and hair. It is overwhelmingly an infection of prepubertal children, but is being increasingly recognized in adults though it was once considered to be uncommon in this age-group.[1] Microsporum canis (M. canis) is the dominant cause of tinea capitis in Greece.[2] In this article we present probably the oldest patient with M. canis tinea capitis to be reported in the literature.

Oxcarbazepin-induziertes lokalisiertes Odem am Penis. Oxcarbazepine-induced localized penile edema

Oxcarbazepine is a analogue of carbamazepine with anticonvulsant and analgesic activity. We report a case of localized penile edema caused by oxcarbazepine. The association between the drug and the adverse reaction was confirmed by rechallenge test. This is the first reported case of oxcarbazepine-induced localized penile edema.