Paul M. Benson

Seronegative Secondary Syphilis in a Patient Infected with the Human Immunodeficiency Virus (HIV) with Kaposi Sarcoma: A Diagnostic Dilemma

Reagin and treponemal antibody tests are highly reliable in diagnosing secondary syphilis. However, patients infected with the human immunodeficiency virus (HIV) respond abnormally to antigenic stimulation and may fail to develop typical serologic responses to infections. We report the case of an HIV-infected man with Kaposi sarcoma and secondary syphilis whose VDRL test and fluorescent treponemal antibody-absorbed test were repeatedly nonreactive. Correct diagnosis required biopsy of a skin lesion with silver staining to show spirochetes. Clinicians treating HIV-infected patients should be aware of the problems of serologic diagnosis of syphilis in these patients. Biopsy samples of appropriate tissues and staining for spirochetes may be needed to arrive at the correct diagnosis.

Safety and Efficacy of Intravenous Sodium Stibogluconate in the Treatment of Leishmaniasis: Recent U.S. Military Experience

The efficacy and toxicity of sodium stibogluconate (SSG) at a dosage of 20 mg/(kg.d) for either 20 days (for cutaneous disease) or 28 days (for visceral, mucosal, or viscerotropic disease) in the treatment of leishmaniasis is reported. Ninety-six U.S. Department of Defense health care beneficiaries with parasitologically confirmed leishmaniasis were prospectively followed for 1 year. One patient was infected with human immunodeficiency virus; otherwise, comorbidity was absent. Clinical cure occurred in 91% of 83 cases of cutaneous disease and 93% of 13 cases of visceral/viscerotropic disease. Adverse effects were common and necessitated interruption of treatment in 28% of cases, but they were generally reversible. These included arthralgias and myalgias (58%), pancreatitis (97%), transaminitis (67%), headache (22%), hematologic suppression (44%), and rash (9%). No subsequent mucosal leishmaniasis was identified, and there were no deaths attributable to SSG or leishmaniasis.

Cutaneous and ocular manifestations of Down syndrome

A patient with Down syndrome and extensive elastosis perforans serpiginosa is presented. There is an increased incidence of elastosis perforans serpiginosa, alopecia areata, syringomas, and Norwegian scabies in patients with this syndrome. Ocular findings include slanting of the palpebral fissures, Brushfields spots, nystagmus, and epicanthal folds. Serious ocular complications that may impair vision include keratoconus, congenital cataracts, and retinal detachment.

A Randomized Controlled Trial of Local Heat Therapy Versus Intravenous Sodium Stibogluconate for the Treatment of Cutaneous Leishmania major Infection

Background Cutaneous Leishmania major has affected many travelers including military personnel in Iraq and Afghanistan. Optimal treatment for this localized infection has not been defined, but interestingly the parasite is thermosensitive. Methodology/Principal Findings Participants with parasitologically confirmed L. major infection were randomized to receive intravenous sodium stibogluconate (SSG) 20mg/kg/day for ten doses or localized ThermoMed (TM) device heat treatment (applied at 50°C for 30 seconds) in one session. Those with facial lesions, infection with other species of Leishmania, or more than 20 lesions were excluded. Primary outcome was complete re-epithelialization or visual healing at two months without relapse over 12 months. Fifty-four/56 enrolled participants received intervention, 27 SSG and 27 TM. In an intent to treat analysis the per subject efficacy at two months with 12 months follow-up was 54% SSG and 48% TM (p = 0.78), and the per lesion efficacy was 59% SSG and 73% TM (p = 0.053). Reversible abdominal pain/pancreatitis, arthralgias, myalgias, headache, fatigue, mild cytopenias, and elevated transaminases were more commonly present in the SSG treated participants, whereas blistering, oozing, and erythema were more common in the TM arm. Conclusions/Significance Skin lesions due to L. major treated with heat delivered by the ThermoMed device healed at a similar rate and with less associated systemic toxicity than lesions treated with intravenous SSG. Clinical Trial Registration ClinicalTrials.gov NCT 00884377

Cutaneous angiosarcoma arising in the radiation site of a congenital hemangioma

We describe a patient in whom angiosarcoma developed at the site of a hemangioma that was treated during infancy with radiation for refractory thrombocytopenia. Our findings, along with those of the 10 reported cases from the world literature, are summarized. One third of angiosarcomas arise in the skin. They most often show one of three clinical patterns. First and most common is occurrence as a bruiselike lesion on the scalp or face of an elderly person. Second in frequency is the Stewart-Treves syndrome. Third and least common is angiosarcoma developing as a sequela of previous radiation therapy. The prognosis in general is poor, with a mean survival length of 24 months and a 5-year survival rate of 10%. Effective treatment relies on early diagnosis and wide-margin surgical excision.

Essential syphilitic alopecia revisited

There has been a resurgence of syphilis in the past decade. Uncommonly, diffuse hair loss, termed essential alopecia, is the only sign of syphilitic infection. We describe two patients with syphilis in whom the first sign of disease was alopecia and discuss the clinical and histopathologic findings of essential syphilitic alopecia.

Basal cell carcinoma of the nipple: Report of two cases

Two cases of basal cell carcinoma of the nipple are presented, bringing the total number of reported cases to 15. The majority, including our two patients, are elderly men. This finding suggests a causal role of exposure to ultraviolet radiation. In our cases excision was curative.

Epithelioid hemangioendothelioma associated with reflex sympathetic dystrophy

A patient with long-standing reflex sympathetic dystrophy of the foot developed an aggressive epithelioid hemangioendothelioma of the involved extremity. The tumor metastasized to a regional lymph node and later to the lungs. The features of epithelioid hemangioendothelioma and reflex sympathetic dystrophy are reviewed.

Phialophora verrucosa: A new cause of mycetoma

A 29-year-old Thai woman had draining sinus tracts, tumefaction, and granules on the plantar aspect of the foot. Phialophora verrucosa was isolated from the lesion. P. verrucosa is a major agent of chromoblastomycosis, which is known to rarely cause subcutaneous phaeohyphomycosis. This dematiaceous fungus has not been previously reported to cause mycetoma. This case illustrates the clinical spectrum of disease of this fungus. The salient features of mycetoma and management options are presented.

Transient, nonpigmenting fixed drug eruption caused by radiopaque contrast media

A unique case of a transient, nonpigmenting fixed drug eruption caused by the radiopaque contrast medium iothalamate is reported. The patient had on the medial aspect of the thigh a fixed solitary, recurrent, indurated, erythematous plaque, which resolved within 2 days. The scant literature available on nonpigmenting fixed drug eruptions is reviewed.