Lisa A. Drage

Herpes zoster (shingles) and postherpetic neuralgia.

Herpes zoster (HZ), commonly called shingles, is a distinctive syndrome caused by reactivation of varicella zoster virus (VZV). This reactivation occurs when immunity to VZV declines because of aging or immunosuppression. Herpes zoster can occur at any age but most commonly affects the elderly population. Postherpetic neuralgia (PHN), defined as pain persisting more than 3 months after the rash has healed, is a debilitating and difficult to manage consequence of HZ. The diagnosis of HZ is usually made clinically on the basis of the characteristic appearance of the rash. Early recognition and treatment can reduce acute symptoms and may also reduce PHN. A live, attenuated vaccine aimed at boosting immunity to VZV and reducing the risk of HZ is now available and is recommended for adults older than 60 years. The vaccine has been shown to reduce significantly the incidence of both HZ and PHN. The vaccine is well tolerated, with minor local injection site reactions being the most common adverse event. This review focuses on the clinical manifestations and treatment of HZ and PHN, as well as the appropriate use of the HZ vaccine.

An outbreak of Mycobacterium chelonae infections in tattoos

Nontuberculous mycobacteria infections may occur after cutaneous procedures. Review of the medical records of patients who developed a rash within a tattoo revealed 6 patients with skin infections caused by Mycobacterium chelonae after receiving tattoos by one artist at a single tattoo establishment. The interval between tattoo placement and the skin findings was 1 to 2 weeks. All patients received alternate diagnoses before mycobacterial infection was identified. Skin findings included pink, red, or purple papules; papules with scale; pustules; granulomatous papules; and lichenoid papules and plaques. Histopathologic examination revealed granuloma, lymphohistiocytic infiltrate, or mixed inflammation; acid-fast bacilli stains produced negative results. Diagnosis was made by culture in 3 patients, histopathology in two patients, and clinical/epidemiologic association in one patient. The M chelonae isolates were clarithromycin susceptible, and the infections responded to macrolide antibiotics. Physicians should consider mycobacterial infections in patients with skin findings within a new tattoo.

Increased Incidence of Cutaneous Nontuberculous Mycobacterial Infection, 1980 to 2009: A Population-Based Study

OBJECTIVES To determine the incidence and clinical characteristics of cutaneous nontuberculous mycobacterial (NTM) infection during the past 30 years and whether the predominant species have changed. PATIENTS AND METHODS Using Rochester Epidemiology Project data, we identified Olmsted County, Minnesota, residents with cutaneous NTM infections between January 1, 1980, and December 31, 2009, examining the incidence of infection, patient demographic and clinical features, the mycobacterium species, and therapy. RESULTS Forty patients (median age, 47 years; 58% female [23 of 40]) had positive NTM cultures plus 1 or more clinical signs. The overall age- and sex-adjusted incidence of cutaneous NTM infection was 1.3 per 100,000 person-years (95% CI, 0.9-1.7 per 100,000 person-years). The incidence increased with age at diagnosis (P=.003) and was higher in 2000 to 2009 (2.0 per 100,000 person-years; 95% CI, 1.3-2.8 per 100,000 person-years) than in 1980 to 1999 (0.7 per 100,000 person-years; 95% CI, 0.3-1.1 per 100,000 person-years) (P=.002). The distal extremities were the most common sites of infection (27 of 39 patients [69%]). No patient had human immunodeficiency virus infection, but 23% (9 of 39) were immunosuppressed. Of the identifiable causes, traumatic injuries were the most frequent (22 of 29 patients [76%]). The most common species were Mycobacterium marinum (17 of 38 patients [45%]) and Mycobacterium chelonae/Mycobacterium abscessus (12 of 38 patients [32%]). In the past decade (2000-2009), 15 of 24 species (63%) were rapidly growing mycobacteria compared with only 4 of 14 species (29%) earlier (1980-1999) (P=.04). CONCLUSION The incidence of cutaneous NTM infection increased nearly 3-fold during the study period. Rapidly growing mycobacteria were predominant during the past decade.

Burning mouth syndrome

Burning mouth syndrome is the occurrence of oral pain in a patient with a normal oral mucosal examination. It can be caused by both organic and psychologic or psychiatric factors, which can be broken down into local, systemic. psychologic or psychiatric, and idiopathic causes. The most frequently associated conditions are psychiatric (depression, anxiety, or cancerphobia); xerostomia; nutritional deficiency; allergic contact dermatitis; candidiasis; denture-related pain: and parafunctional behavior. Multiple different factors contributing to the oral pain are common, and a systematic approach to the evaluation is important. Identification of correctable causes of BMS should be emphasized and psychiatric causes should not be invoked without thorough evaluation of the patient. A directed history and careful oral examination must be completed to exclude local diseases and identify clues to potential causes. Assessment of medications, psychiatric history and background, and selected laboratory and patch tests may help identify the etiologies of these symptoms. Treatment should be tailored to each patient and may best be managed in a multidisciplinary approach with input from dermatologists, dentists, psychiatrists. otorhinolaryngologists, and primary care providers. A thoughtful and structured evaluation of the patient with BMS has been associated with improvement in about 70% of patients. The remaining patients may benefit from empiric therapy with a chronic pain protocol and continued supportive interactions.

Nontuberculous Mycobacteria: Skin and Soft Tissue Infections

Skin and soft tissue infections caused by nontuberculous mycobacteria are increasing in incidence. The nontuberculous mycobacteria are environmental, acid-fast bacilli that cause cutaneous infections primarily after trauma, surgery and cosmetic procedures. Skin findings include abscesses, sporotrichoid nodules or ulcers, but also less distinctive signs. Important species include Mycobacterium marinum and the rapidly growing mycobacterium: M. fortuitum, M. abscessus and M. chelonae. Obtaining tissue for mycobacterial culture and histopathology aids diagnosis. Optimal therapy is not well-established, but is species-dependent and generally dictated by susceptibility studies. Management often includes use of multiple antibiotics for several months and potential use of adjunctive surgery.

Clinical assessment and outcome in 70 patients with complaints of burning or sore mouth symptoms

OBJECTIVE To review a series of patients with a burning or sore mouth for elucidation of associated conditions and treatment outcome. MATERIAL AND METHODS We retrospectively studied 70 consecutive patients with a burning or sore mouth who were encountered at a tertiary-care center between 1979 and 1992. Clinical and laboratory findings were summarized, and follow-up data were analyzed. RESULTS The study cohort of 56 women and 14 men had a mean age of 59 years. They had had a burning or sore mouth for a mean duration of 2.5 years. Multiple etiologic factors for the burning or sore mouth were present in 37% of the study subjects. The most frequently associated conditions were psychiatric disease (30%), xerostomia (24%), geographic tongue (24%), nutritional deficiencies (21%), and allergic contact stomatitis (13%). With a treatment course tailored to the suspected causal factor, 72% of the patients who had follow-up reported improvement. CONCLUSION With a directed investigation, one or more causes could be identified in most patients who had a burning or sore mouth. Successful management of these symptoms was possible in a majority of the patients.

Clinical and histopathologic review of Schnitzler syndrome: The Mayo Clinic experience (1972-2011)

BACKGROUND Schnitzler syndrome is a rare multisystem disorder, defined by urticaria and monoclonal gammopathy, that is associated with malignancy. Considered a neutrophilic urticarial dermatosis, previous reports have included patients with leukocytoclastic vasculitis. OBJECTIVE We sought to better define the clinical features, histopathology, and outcomes of Schnitzler syndrome. METHODS We retrospectively reviewed clinical records and cutaneous histopathology of all patients with Schnitzler syndrome seen at our institution from January 1, 1972, through July 31, 2011. RESULTS Of the 20 patients identified, 80% had IgM κ monoclonal gammopathy; others had IgG λ (10%), IgG κ (5%), or IgM κ+λ (5%). Patients had fevers (85%), arthralgias (70%), leukocytosis (70%), increased erythrocyte sedimentation rate (70%), bone pain (50%), lymphadenopathy (40%), and organomegaly (5%); 45% developed a hematologic malignancy. Histopathologic examination (n = 14) showed predominantly neutrophilic perivascular and interstitial inflammation (57%) or predominantly mononuclear cell perivascular inflammation (29%), with eosinophils in 50% of cases. None showed leukocytoclastic vasculitis. LIMITATIONS Our study was limited by its retrospective design. CONCLUSION We added 20 patients to approximately 100 reported cases of Schnitzler syndrome. Neutrophilic urticarial dermatosis was the most common histopathologic pattern, but mononuclear cells were predominant in many cases and the infiltrates often contained eosinophils. A high index of suspicion and careful clinicopathologic correlation are needed to avoid diagnostic delays in this syndrome associated with hematologic malignancy.

Life-Threatening Rashes: Dermatologic Signs of Four Infectious Diseases

Four infectious diseases that are associated with high rates of morbidity and mortality are Rocky Mountain spotted fever, meningococcal disease, staphylococcal toxic shock syndrome, and streptococcal toxic shock syndrome. These diseases necessitate a timely diagnosis and treatment, which may be facilitated by recognition of the characteristic cutaneous findings. Herein the clinical manifestations, diagnosis, and management are presented, with emphasis on the dermatologic signs of each disease. A dermatology consultation can be valuable, but all physicians should be familiar with the cutaneous findings of these potentially life-threatening diseases.

Skin necrosis secondary to low-molecular weight heparin in a patient with antiphospholipid antibody syndrome.

Skin necrosis is a rare complication of subcutaneous heparin therapy that usually occurs at injection sites. It occasionally accompanies the heparin-associated thrombocytopenia and thrombosis syndrome. We describe a patient with the antiphospholipid syndrome who had skin necrosis develop from low-molecular weight heparin therapy at sites distant from injection sites.

Clinically relevant patch test results in patients with burning mouth syndrome.

BackgroundPatients with a sore or burning mouth associated with clinically normal oral mucosa present a difficult diagnostic challenge. ObjectiveThe objective of this study was to assess the value of patch testing in patients with burning mouth syndrome. MethodsWe retrospectively reviewed the results of patch testing to an oral series in patients with burning mouth syndrome seen at Mayo Clinic, Rochester, Minnesota, between January 2000 and April 2006. ResultsOf 195 consecutive patients with a burning or sore mouth, 75 had patch testing to an oral series, and 28 of these patients (37.3%) had allergic patch test reactions. The most common allergens were nickel sulfate hexahydrate 2.5%, balsam of Peru, and gold sodium thiosulfate 0.5%. On follow-up, 15 patients reported improvement, 4 removed or avoided the offending dental metal, and 6 avoided the dietary allergen. Thirteen patients did not improve; 6 avoided identified allergens, but without improvement; 1 removed dental metals without symptom change; and 5 avoided test-positive dietary allergens but without improvement. The remaining 7 nonresponders had nonrelevant patch test results or did not avoid allergens. ConclusionsPatch testing can identify patients who may be allergic to dental metals or dietary additives and who may benefit from removal or avoidance of these.