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Bullous pemphigoid: associations and management guidelines: facts and controversies.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the Editor following the discovery that the text overlaps significantly with sections of several articles that are cited in the reference section, including the following: Culton DA, Diaz LA. Treatment of subepidermal immunobullous diseases. Clin Dermatol 2012;30:95–102. Meurer M. Immunosuppressive therapy for autoimmune bullous diseases. Clin Dermatol 2012;30:78–83. Ljubojevic S, Lipozencic J. Autoimmune bullous diseases associations. Clin Dermatol 2012;30:17–33. Sehgal VN, Verma. Leflunomide: dermatologic perspective. J Dermatolog Treat 2013;24:89–95. Gürcan HM, Ahmed AR. Analysis of current data on the use of methotrexate in the treatment of pemphigus and pemphigoid. Br J Dermatol 2009;16:723–31. Chen YJ, Wu CY, Lin MW, et al. Comorbidity profiles among patients with bullous pemphigoid: a nationwide population-based study. Br J Dermatol 2011;165:593–9

Scrofuloderma: a forgotten disease?

To the Editor: We report the case of a 72-year-old Italian woman referred to our dermatology department with multiple abscesses on both sides of the neck (Figure 1). The lesions had developed as asymptomatic subcutaneous nodules that evolved into ulcers with pus discharge after 3 months. On admission, the patient showed multiple erythematous, well-defined, freely movable, 20 to 40 mm nodules, some of which ruptured and spontaneously drained or scarred (Figure 2). On physical examination, the patient had a fever (38.7uC) and cervical lymphadenopathy; other vital signs were within normal limits, and the skin demonstrated no other significant changes. She had no background of immunosuppression and no family history of tuberculosis, and she had never received the antituberculosis vaccine. Laboratory evaluations revealed impaired glucose tolerance (glycemia 118 mg/dL [normal value 100 mg/dL]), neutrophil leukocytosis (white blood cell count 10,780/mL [normal value 4,000–10,000/mL]; neutrophils 88.9% [normal value 55–70%]), an elevated erythrocyte sedimentation rate (43 mm/hr, normal value male , 20 mm/hr, female , 30 mm/hr), and elevated C-reactive protein (1.97 mg/dL [normal value , 1 g/dL]). The tumor markers values were normal (carcinoembryonic antigen 4.2 ng/mL [normal value 0–5 ng/mL]; CA 19-9 3.7 U/mL [normal value 0–35 U/mL]; CA 50 0.2 U/mL [normal value 0– 20 U/mL]; tissue polypeptide antigen (TPA) 12.7 mU/mL [normal value 0–110 mU/m]; neuron-specific enolase (NSE) 0.3 ng/mL [normal value 0–11 ng/mL]). Serum human immunodeficiency virus (HIV) and Veneral Disease Research Laboratory (VDRL) tests were negative. A purifed protein derivative (PPD) skin test was already positive after 24 hours (17 mm [normal value , 15 mm]). Smear for acid-fast bacilli by Ziehl-Neelsen staining was positive. Cultures from skin biopsy showed the growth of Mycobacterium tuberculosis after 8 weeks. An anteroposterior chest radiograph revealed pulmonary involvement: striae, nodular fibrosis, and pleural thickening. Abdominal ultasonography was negative. All of these findings were consistent with a diagnosis of scrofuloderma, the most common form of cutaneous tuberculosis in adults. Cutaneous tuberculosis is a rare infection (1% of all cases of tuberculosis), but it is still present in immunocompromised patients (due to HIV, use of immunosuppressants, or malignancy), travelers, or immigrants from developing countries. M. tuberculosis, Mycobacterrium bovis, and the bacille Calmette-Guérin vaccine can cause tuberculosis involving the skin. Scrofuloderma can result from contiguous involvement of skin overlying tuberculosis in a deeper structure, expecially the lymph nodes and, less commonly, the bones, joints, or epididymis; there have also been reports of scrofuloderma following surgical drainage of joints and infection of the lacrimal system. Moreover, cutaneous tubercular abscess can occur from extension of an embolism to subcutaneous tissue (such as pulmonary foci or direct skin inoculation). Cervical gland disease is the most common site of involvement in scrofuloderma. Scrofuloderma presents in a wide variety of clinical forms depending on how bacteria reach the skin and on the immune status of the patient. If there is an underlying tuberculous lymphadenitis or bone and joint disease, the diagnosis usually presents no difficulty. Positive results on culture confirm the diagnosis. The differential diagnosis includes Mycobacterium avium intracellular lymphadenitis, Mycobacterium scrofulaceum infection, syphilitic gummas, actinomycosis, severe forms of acne conglobata, and hidradenitis suppurativa. In our case, antitubercular treatment was initiated with rifampicin 600 mg/d and isoniazid 600 mg/d, and the lesions showed an improvement within 4 weeks of therapy. On this regimen, the skin lesions cleared within 2 months. After 8 weeks of therapy, patients are usually no longer considered infectious but still require longer-term treatment for eradication, so medications were continued for a further 7 months. Meanwhile, peripheral blood count and renal and liver functions were steadily monitored. Resolution with antitubercular therapy has been durable, with a current follow-up of 12 months. Tuberculosis has been associated with humanity since ancient times. It is a disease of global importance: over 2 million deaths are attributed to this infectious disease each year. Even in areas where tuberculosis was in decline, such as in Italy, there are sporadic outbreaks, which are often attributed either to increased host susceptibility or increased strain transmissibility and virulence. Tuberculosis is often an occult disease, and its diagnosis is made during screening for other diseases or, most frequently in the dermatologic field, during screening before starting immunosuppressant DOI 10.2310/7750.2013.12106