Maria Rosaria Zampino

Fungal Skin Infections in Organ Transplant Recipients

Transplantation is now currently and increasingly performed for the treatment of various acute and chronic diseases. Today the kidney, heart, lung, heart-lung, liver, pancreas, kidney-pancreas, small bowel and bone marrow are being transplanted. The immunological status of patients receiving such transplants exposes them to the risk of developing bacterial, viral and fungal infections.The etiological agents of mycotic diseases involving the skin of transplant recipients range from the common dermatophytes through yeasts such as Candida spp., Malassezia spp. and dimorphic fungi to the emerging molds Fusarium spp. and Pseudallescheria boydii.The very wide spectrum of fungi causing cutaneous disease produces equally varied clinical aspects. Lesions may be typical, but are very often aspecific or ambiguous.Cutaneous lesions may be the sign of a trivial mycotic disease or the marker of a disseminated, potentially lethal fungal illness, so great attention should be given to their early recognition.Cutaneous manifestations due to Candida spp., Aspergillus spp., dematiaceous fungi and Pityrosporum folliculitis are usually observed early after transplant, cryptococcosis more than 6 months later, while the frequency of dermatophytoses increases as time goes by. Coccidioides immitis, Histoplasma capsulatum and Blastomyces dermatitidis may appear any time after transplantation.The management of the more severe forms of cutaneous mycosis in transplant recipients is difficult. Besides the fact that early recognition is not easy, there are also problems regarding the effectiveness and the toxicity of the therapy and drug-drug interactions.Prophylactic measures to avoid fungal contamination must be performed during hospitalization; patients should be taught how to avoid contamination, not only during the first period after transplantation, when high dosage immunosuppressive drugs are given, but also later when a normal lifestyle is resumed.

Primary Cutaneous CD30+ Large T-Cell Lymphoma in a Patient with Psoriasis Treated with Cyclosporine

We report the case of a 61-year-old woman who developed an anaplastic CD30+ cutaneous T-cell lymphoma during oral cyclosporine (CsA) therapy for recalcitrant psoriasis. Two months after CsA discontinuation, clinical and histological resolution of the lymphoma was observed. However, 3 years later extracutaneous involvement of the lymphoma could be detected. The association between CsA administration and the occurrence of the lymphoma may be casual, but a relationship with immunosuppression may also be hypothesized. We have reviewed all relevant data in the literature. To our knowledge, this is the first case of primary cutaneous CD30+ anaplastic large T-cell lymphoma in a patient treated with CsA for psoriasis.

Lichenoid reaction from a permanent red tattoo: has nickel a possible aetiologic role?

A 27-year-old man had been tattooed by a professional tattooist 8 months before presentation. He had a large polychrome tattoo over his right deltoid, in which numerous purplish pruriginous papules had persisted since a few weeks after tattooing, restricted to the red areas of the tattoo (Fig. 1). Patch tests with the Italian SIDAPA series showed a ππ π D2/ππ π D3 reaction to nickel sulfate. A strong ππ D2/ππ π D3 reaction was also obtained to the original ‘cardinal red’ pigment used to tattoo the red areas. Patch tests with cobalt sulfate 2% pet., cadmium sulfate 2% pet., ammoniated mercury 1% pet. and copper sulfate 1% aqueous were all negative. A skin biopsy of the red papular lesions showed a bandlike dense lymphocytic infiltrate in the superficial dermis, focal liquefaction degeneration in the basal layer, exocytosis and occasional colloid bodies. There were numerous macrophages containing small pigment granules in the infiltrate. The clinical features, patch tests and biopsy led us to diagnose a chronic lichenoid allergic contact dermatitis due to the red pigment of the tattoo. The material safety data sheet of the ‘cardinal red’ dye declared monoazo pigment, cinnabar and traces of the heavy metals lead, mercury, cadmium, chromium and selenium, but no nickel. Further investigation was therefore performed. After microwave acid digestion, graphite furnace atomic absorption spectroscopy of the original red dye was performed on 3 parts of the sample, which demonstrated the presence of nickel at 1.90 ∫ 0.34 ppm in the pigment. Treatment with a potent topical corticosteroid 2¿ daily for 2 months only slightly improved the dermatitis.

Relapsing Tinea capitis by Microsporum canis in an Adult Female Renal Transplant Recipient

Scalp ringworm is very uncommon in adults. The occurrence and the atypical clinical course of this unusual dermatophytosis in a female renal transplant recipient are described. Furthermore, the prevalence and the clinical features of superficial fungal infection in renal transplant recipients are reviewed. As immunosuppression enhances the risk of antifungal therapy failure, more prolonged treatment and careful follow-up are necessary to obtain complete recovery from any dermatophytosis in renal transplant recipients.

ATYPICAL FEATURES OF TINEA IN NEWBORNS

To the Editor: We observed three babies, ages 2 months, 43 days, and 25 days, affected by atypical features of tinea faciei and capitis. These features resembled the dermatoses most frequently observed in this period of life. Both cheeks in the first baby and the head in the others had been affected for 5 to 20 days. Lesions were similar to atopic dermatitis of the face and to seborrheic dermatitis of the head (Figs. 1 and 2). Microscopic and cultural examinations were positive for Microsporum canis in all three infants; the mothers and/or brothers or sisters were also affected by tinea corporis. Only about 40 cases of tinea in infants are described in the literature (1-5). The etiologic agent depends on the geographic area; Microsporum canis is the most common (1,2,6), whereas Trichophyton rubrum and Trichophyton mentagrophytes are frequent in Japan (2). The cephalic area is affected most frequently, perhaps due to greater temporal exposure of the head to contact with infected sources, such as mother or pets. The rare occurrence of tinea in newboms and its atypical clinica! aspect may lead physicians to diagnose other dermatites more typical in this age group, such as seborrheic dermatitis, cutaneous candidiasis, bacterial infections, or atopic dermatitis. In fact, tinea capitis in children may assume an aspect known as seborFigure 2. Seborrheic dermatitis-like tinea capitis.

Conventional patch tests are poor detectors of contact allergy from ophthalmic products

A total of 32 patients consecutively examined for dermatitis related to the use of topical ocular products (eyedrops, ophthalmic ointments, detergents for contact lenses) were enrolled in this study. The patients gave either a positive stop–restart test or a highly suggestive history of intolerance to topical ophthalmics. The patients (8 males and 24 females), mean age 56 (range 25–86), all had eyelid dermatitis (22 patients) or persistent erythematous–oedematous reaction of the eyelids (10 patients) after the use of such products. Ophthalmologic therapies had been prescribed for glaucoma (16 cases), intolerance to contact lenses (2), Sjögren syndrome (3), cataract (1), infections (6) and various other ocular conditions (4). Atopy was found in 5 cases but none had clearly atopic allergic conjunctivitis. History established the use of eyedrops and/ or ointments in 30 of the 32 patients. The others were using ocular detergents/disinfectants for ocular conditions and care of contact lenses. All patients were patch tested with the Italian SIDAPA standard series and a preservatives–antimicrobials series. Patch tests were also performed with our integrative series of excipients of topical ophthalmic products: sodium EDTA 1% pet., monobasic sodium phosphate 1% aq., hydroxypropylcellulose 25% alc., hydroxyethylcellulose 25% alc., and dibasic sodium phosphate 1% aq. They were also tested with their own products, applied as is in Finn Chambers. We also tested the ocular medicaments that the patients blamed for having induced dermatological problems in the past.

Allergic contact dermatitis due to an insect repellent: double sensitization to picaridin and methyl glucose dioleate.

Sir, Picaridin, a piperidine derivate, is a promising insect repellent that has been available to the consumer since 1998 (1). Picaridin protects against arthropods in a similar fashion to diethyl toluamide (deet), which is considered the gold standard compound (2, 3). Picaridin is also better tolerated than deet (1, 4), a fact that has encouraged its use in repellent formulations. We describe here the first case of contact allergy to picaridin consequent to the application of an insect repellent aerosol for cutaneous use. Furthermore the patient was also sensitized to methyl glucose dioleate, an emulsifier of the aerosol, confirming its sensitizing potential.

Primary Vulvar Melanoma with Satellite Metastasis: Dermoscopic Findings

A 79-year-old woman presented with a 1-year history of a pigmented nodular lesion on the left labium minor. Histopathology of the nodule led to a diagnosis of metastatic melanoma. A pigmented flat lesion on the inner side of the left labium major was also biopsied and was found to be a superficial spreading melanoma. The dermoscopic findings of primary and metastatic vulvar melanoma which simultaneously occurred in the same patient are described. Dermoscopy revealed a homogeneous pattern associated with linear irregular vessels in the metastatic nodule, while irregular globules and streaks were seen in the primary melanoma.

Vulvar Melanocytic Nevi: A Dermoscopic Investigation

Background: Very few dermoscopic investigations into pigmented genital lesions have been performed to date. To the best of our knowledge, no dermoscopical description of vulvar melanocytic nevi (MN) has yet been proposed. Objective: Our aims were to analyze the dermoscopic features of vulvar MN and to review the literature of dermoscopy of the vulvar area. Methods: Among 74 women presenting 84 vulvar pigmented lesions, 10 who received a visual diagnosis of MN were submitted to dermoscopic and histopathological analysis. Results: Histology confirmed the clinical diagnosis of MN in 8 out of 10 cases, while the remaining 2 pigmented lesions were diagnosed as seborrheic keratosis. Vulvar MN were generally found to share similar dermoscopic patterns with their cutaneous equivalent. Conclusions: Although further observation will be necessary to provide additional data and establish key morphological criteria and/or algorithms useful for differentiating between melanocytic and nonmelanocytic vulvar lesions, dermoscopy should be considered an investigative tool, as clinical observation alone may not be sufficient for accurate diagnosis.

HLA typing in an IFN-alpha-induced scar sarcoidosis: possible pathogenetic and clinical implications.

Sin Sarcoidosis as a complication ofinterferon (IFN) administration was first described in 1987 in a patient with renal cancer (I). Since then, more than 50 cases of pulmonary and/or cxtra-puhnonary sarcoidosis. mainly occurring in middle-aged women, have been correlated with IFN-a therapy, sometimes associated with ribavirin, in patients with chronic viral hepatitis C (2.3). Several lines of evidence suggest that HLA class I and class II alíeles may be considered possible markers for susceptibility, clinical behaviour and prognosis of sarcoidosis (4, 5). We report here a case of scar sarcoidosis that occurred one month after completion of a course of pegylatedlFN-a therapy for chronic hepatitis C virus (HC V) infection. HLAtyping was perfomied to evaluate the potential role of an immunogenetic predisposition factor.