John B. Fournier

Resolution of autoimmune progesterone dermatitis after treatment with oral contraceptives

OCP: oral contraceptive pill CASE REPORT A 20-year-old woman presented with a 6-year history of recurrent erythematous papules and plaques on the trunk. The eruption recurred cyclically, beginning 5 days before menses and resolving 1 to 2 days after the menstrual period. The lesions were asymptomatic, and there were no associated systemic symptoms. She had not previously sought treatment. Her medical history was unremarkable, and she was not taking any medications. Examination found widespread erythematous and edematous papules and nonscaly plaques, on the chest, back, and lower neck (Fig 1). Lesions were uniform in color, ranging in size from 3mm to 4 cm in diameter. A biopsy specimen was taken for histopathologic evaluation (Fig 2). Results of a punch biopsy of the skin showed dermal perivascular lymphohistiocytic inflammation, with rare eosinophils. An intradermal progesterone test read at 20 minutes was positive (progesterone, 50 mg/mL at a dilution of 1:10 in aqueous solution elicited a 10-mm wheal vs a 4-mm wheal for the glycerine control). The patient was started on levonorgestrel/ ethinyl estradiol, 0.1 mg to 20 g daily. There was a marked reduction in the number of lesions during her next menstrual period. By the third menstrual cycle, after beginning oral contraceptive pills (OCPs), no lesions appeared perimenstrually. The patient remained clear for another 4 months while taking Levonorgestrel/Ethinyl Estradiol 0.1 mg to 20 g. She then discontinued treatment because of the loss of health insurance. Despite discontinuing OCPs, lesions have not returned in the 8 months since the medication was stopped.

A Case Report of Cushing’s Disease Presenting as Hair Loss

Cushing’s syndrome is a rare endocrine disorder that comprises a large group of signs and symptoms resulting from chronic exposure to excess corticosteroids. Most cases of Cushing’s syndrome are due to increased adrenocorticotropic hormone production from a pituitary adenoma, which is referred to as Cushing’s disease. Most of the signs and symptoms are nonspecific and common in the general population, making a diagnosis often challenging. However, several dermatological manifestations, such as fragile skin, easy bruising, and reddish purple striae, are more discriminatory. Because uncontrolled Cushing’s syndrome of any etiology is associated with substantial morbidity, including increased cardiovascular disease and mortality, it is important to make an early diagnosis. Unfortunately, median delays of 2 years to diagnosis have been reported. We report a case of a woman who had multiple dermatological findings, including facial plethora, easy bruising, violaceous striae, hirsutism, and acne, the latter 2 signs reflecting androgen excess. Of interest, our patient presented with a chief complaint of hair loss, a common complaint in the general population that occurs with a greater frequency in patients with Cushing’s disease and is attributed to androgenetic alopecia, but it is rarely the presenting symptom.

A case of African tick-bite fever in a returning traveler

A healthy 30-year-old man spent a week on safari in Kenya in late February to early March. He received typhoid and yellow fever vaccines prior to his travel, and took atovaquone/proguanil for malaria prophylaxis while there. Three days after his return to the US, a red, papular rash appeared on his chest (Fig. 1), followed by fatigue, chills, sweats, and high fevers. He noticed a swollen lymph node in his left groin and a lesion on the anterior aspect of the left foot that was pustular, swollen, and painful. The rash on his chest spread to his groin, several new enlarged lymph nodes appeared in his neck, and the lesion on his foot progressed to a small eschar (Fig. 2). Initial labs were unremarkable. A rapid throat swab for Group A Streptococcus was negative as were cultures for Streptococcus Groups A, C, and G, Monospot test, HIV antibody/antigen, malaria and babesia smears, Lyme serology, and gonorrhea and chlamydia PCR. Rickettsial disease panel was positive for Rickettsia typhi IgG but not IgM. Further study resulted R. conorii IgG titer of 1:8192 and R. africae IgG titer of 1:1024. A punch biopsy of the eschar revealed epidermal and superficial dermal necrosis with focal necrotizing vasculitis with a brisk superficial and deep lymphohistiocytic infiltrate suggestive of a tick-borne illness (Figs. 3 and 4). Biopsy of the rash revealed similar vascular damage. The tissue was submitted to the Center for Disease Control and Prevention and R. africae was confirmed by PCR, supporting a diagnosis of African Tick Bite Fever (ATBF). The patient was treated with 10days of doxycycline. ATBF is a zoonotic disease caused by infection with R. africae and transmitted by Amblyomma ticks in sub-Saharan Africa [1,2]. Common symptoms include fever, one ormore inoculation eschars (tache noire), and regional lymphadenopathy. Rash is frequently absent and complications are uncommon [1–3]. The eschar can be the site of inoculation and rickettsial multiplication, making it the preferred biopsy site to distinguish ATBF from other rickettsioses due to cross-reactivity by immunofluorescence [1,4,5]. As seen in our case, positive rickettsial titers are reliable for infection with rickettsial disease, although unreliable for speciation. R. conorii is an important differential as it is also present in sub-Saharan Africa

Frequency of Syphilis Diagnoses by Dermatologists

Author Contributions: Drs Robinson and Turrisi had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Robinson, Nodal, Mallett, Turrisi. Acquisition, analysis, or interpretation of data: Chavez, Ali, Turrisi. Drafting of the manuscript: Robinson, Turrisi. Critical revision of the manuscript for important intellectual content: Nodal, Chavez, Ali, Mallett, Turrisi. Statistical analysis: Turrisi. Administrative, technical, or material support: Robinson, Nodal, Chavez, Ali. Study supervision: Turrisi.

Serratia marcescens Bullous Cellulitis in a Splenectomized Patient A Case Report and Review of the Literature

Serratia marcescens is a Gram-negative bacillus belonging to the Enterobacteriaceae family. Cutaneous infection with Serratia is rare, and usually occurs in immunocompromised individuals. Primary cutaneous infections are uncommon, but they are typically severe and are associated with significant morbidity and mortality. The pathogenetic factors leading to S. marcescens infection are not fully understood, but contributing virulence factors include proteases, secreted exotoxins, and the formation of biofilm. We report a case of cellulitis occurring in a splenectomized patient, which led to multiple wound debridements and a transmetatarsal amputation. This dramatic case led us to review the published literature on soft tissue infections caused by S. marcescens.

Unilateral Erythema Nodosum following Norethindrone Acetate, Ethinyl Estradiol, and Ferrous Fumarate Combination Therapy

Erythema nodosum is a septal panniculitis that typically presents as symmetric, tender nodules on the anterior aspects of bilateral lower extremities. Nearly half of cases are due to secondary causes, with oral contraceptive pills being the leading pharmaceutical cause. However, to our knowledge, there has yet to be a published association with norethindrone acetate, ethinyl estradiol, and ferrous fumarate. We report our experience with a 30-year-old woman who developed unilateral tender nodules within a month of starting 1 mg norethindrone acetate and 20 mcg ethinyl estradiol daily. Of note, she had previously taken oral contraceptives with the same estrogen agent but different progesterone, without problems. We conclude that systemically triggered erythema nodosum can present with lesions localized to one extremity. When a patient presents with tender, firm nodules, clinicians should consider the possibility of erythema nodosum and its triggers, such as oral contraceptives. Additionally, should a patient on hormonal therapy develop erythema nodosum, changing the progesterone agent may allow the patient to continue similar therapy without developing symptoms.

Family Outbreaks of Nontyphoidal Salmonellosis following a Meal of Guinea Pigs

Salmonella outbreaks have been linked to a wide variety of foods, including recent nationwide outbreaks. Guinea pig (Cavia porcellus), also known as cuy or cobayo, has long been a popular delicacy and ceremonial food in the Andean region in South America. This case report describes three family outbreaks of nontyphoidal salmonellosis, each occurring after a meal of guinea pigs. We believe this case report is the first to describe a probable association between the consumption of guinea pig meat and human salmonellosis. Physicians should be aware of the association of Salmonella and the consumption of guinea pigs, given the increasing immigration of people from the Andean region of South America and the increasing travel to this region.