Ranju Rai

Childhood cutaneous tuberculosis: a study over 25 years from northern India

Abstract

Majocchi’s granuloma trichophyticum in an immunocompromised patient

A 40‐year‐old man with alcoholic liver disease was referred to the dermatology clinic for asymptomatic papulonodular lesions over the face of 15 days’ duration. Cutaneous examination revealed multiple, dusky red to yellow, follicular as well as perifollicular papulonodular lesions, varying in size from 0.5 to 2 cm ( Fig. 1 ). They were distributed over the forehead, cheeks, eyelids, nose, chin, beard area, retroauricular area, and neck. Careful examination revealed well‐defined scaly margins on the back of the pinna ( Fig. 2 ). KOH examination of a scraping from the neck revealed nonpigmented septate hyphae. Histopathologic examination of the excised nodule revealed epitheloid cell granulomas with neutrophilic microabscesses surrounding the hair follicles. Periodic acid–Schiff stain was noncontributory. Culture of an excised nodule on Sabouraud’s agar showed growth of Trichophyton rubrum. Considering his liver disease, the patient was initially treated with topical terbinafine. Because of a lack of a satisfactory response this was changed to oral terbinafine 250 mg/day. There was marked regression of the lesions by the sixth day. Unfortunately, the patient succumbed to complications relating to his liver disease.

Nail involvement in leprosy: a study of 300 patients.

Three hundred leprosy patients were recruited to study the pattern and frequency of nail changes. Nail changes, like longitudinal ridging in finger nails, transverse striations involving both finger and toe nails etc. which occurred with similar frequency in the PB and MB patients in comparison with the control group, were excluded from the analysis. Out of a total number of 150 PB patients, 84 (56%) showed nail changes. Fifty-eight (38.6%) patients showed changes in the finger nails, with an average of 3.2 involved nails per patient. Fifty-three (35.3%) patients showed changes in the toe nails, with an average of 3.0 nails per patient. The most common change observed was longitudinal melanonychia (32.4%) in the finger nails and longitudinal ridging (46.3%) in the toe nails.In comparison, 131/150 (87.3%) MB patients showed nail changes. Finger nail changes were seen in 102 (68%) patients with an average of 5.5 nails affected per patient. Changes in toe nails were seen in 116 (77.3%) patients, with an average of 6.0 nails involved per patient. The most common nail change observed was longitudinal melanonychia in 89/523, (17%) of the total involved finger nails and subungual hyperkeratosis in 164/702, (23.4%) of the total toe nails involvement. Out of a total of 32 colony patients, 31 (96.9%) showed nail changes both in finger and toe nails with an average of 7.9 and 8.4 affected nails per patient, respectively. The most common nail change observed was rudimentary nail(s) on fingers (29%) and toes (21.1%). Among MB patients, a significantly higher number had finger nail involvement in LL group. The frequency of nail involvement for both fingers and toes was significantly greater in LL as compared to BL group of patients. The frequency of nail involvement was significantly more in patients having disease for more than 5 years and in those having trophic changes secondary to loss of sensations and impaired circulation.

Multiple, Large, Polypoid Infundibular (Epidermoid) Cysts in a Cyclosporin-Treated Renal Transplant Recipient

Epidermoid cysts are keratin-containing cysts lined by epidermis. They present as single or multiple, spherical, slightly compressible, intradermal or subcutaneous masses, few millimeters to few centimeters in size. Rarely, a single cyst may acquire a very large size [1]. We report a case of multiple, large, polypoid epidermoid cysts in a renal transplant recipient receiving immunosuppressive drugs. A 23-year-old male patient presented with large, cystic masses on the buttocks of 3 years’ duration. He was receiving cyclosporin, azathioprine and prednisolone for his kidney transplantation, which had been done about 3 years previously. However, at the time of presentation, his transplanted kidney was in a state of rejection. The cysts started developing about 3 months after transplantation. Since then, new cysts were emerging and old ones were enlarging. Examination revealed multiple, polypoid, soft cystic lesions located over the medial aspect of the buttock and both greater trochanters of the femur in a bilateral symmetrical distribution. Many large cysts were pedunculated (fig. 1). The size of the cysts ranged from 1 to 8 cm. The overlying skin was covered with prominent blood vessels and was inflamed and ulcerated in some places. Many keratonic plugs were seen in the affected areas. The masses were well defined, soft, cystic, nontender lumps. On exploration under local anesthesia, multiple, soft, yellow or blue encapsulated cysts were revealed. The cysts were dissected bluntly from the surrounding tissue. The specimen sent for histopathology revealed cysts filled with horny material, lined by fully keratinized stratified squamous epithelium, suggestive of infundibular cysts. Epidermoid cysts are usually single or few in number except in patients with Gardner’s syndrome who may have numerous cysts [2]. Reports of multiple, giant epidermoid cysts are almost absent in the dermatological literature [1]. Arizpe and Candiani [1] reported a single giant epidermoid cyst which enlarged slowly over a period of 20 years. Our patient had multiple large cysts, which increased in size relatively rapidly in a period of 3 years. The exact etiology of epidermoid cysts is unknown, but many factors, such as trauma, occlusion of pilosebaceous follicles or human papillomavirus (HPV), have been cited as etiological factors [3]. It is unclear, whether HPV is truly an etiological factor or merely a chance association. A case of bowenoid papulosis developing in a penile inclusion cyst has been reported [4], suggesting a possible role of HPV in the causation of both diseases. Schoendorff et al. [5] reported a case of multiple epidermoid cysts receiving cyclosporin A. A study of cutaneous lesions of 67 cyclosporin-treated renal transplant recipients revealed epidermoid cysts in 28% of patients [6]. However, epiFig. 1. Multiple, large, pedunculated epidermoid cysts over the gluteal region. Note keratotic plugs and prominent vessels.

Involvement of male genitalia in leprosy.

Four hundred and sixty-seven male patients with leprosy were screened for genital involvement. Genital lesions were observed in 6.6% of all male cases of leprosy. They were seen most frequently in lepromatous leprosy (25.8%), followed by borderline lepromatous (13.3%) and borderline tuberculoid (1.4%) leprosy.

Lesions resembling polymorphic eruption of pregnancy several years after pregnancy.

A 53-year-old woman presented to the Gynaecology Department with complaints of vaginal discharge and intermittent mild pain in the lower abdomen for the past 4 months. She had reached menopause 3 years back and had no history of bleeding per vaginum after that. She gave a history of losing 6 kg in the past 4 months. On internal examination, her cervix was bulky and bled on touch. A biopsy was taken and she was diagnosed as having cervical cancer (stage IIb) and was advised to undergo radiotherapy. One day prior to the beginning of radiotherapy, she was referred to the Dermatology Department because of intensely pruritic erythematous lesions on her abdomen which had appeared 10 days before. There was no history of any prior drug intake. On examination, she had numerous erythematous 5to 20-mm papuloplaques localised to the striae distensiae on the lower abdomen. A few lesions were topped with pinpoint excoriations and tiny crusts. She recalled having similar lesions during all 4 prior pregnancies, the last of which was 28 years back. Her haemogram, liver and renal function tests were all within normal limits. Scrapings for scabies and tinea were repeatedly negative. A skin biopsy was advised, but could not be done for fear of non-healing as she was about to start radiotherapy the same day. She was advised to apply topical corticosteroids twice a day for 1 week after which there was marked improvement in the lesions. Polymorphic eruption of pregnancy (PEP) is a common, intensely pruritic dermatosis which occurs in approximately 1 in 240 pregnancies [1]. The lesions usually begin and predominate over the striae distensiae, although they can later spread to the thighs, arms and upper abdomen. PEP most often occurs in primigravidae and rarely re-occurs in subsequent pregnancies [2]. In a recent review it has been classified along with pemphigoid gestationis and cholestasis of pregnancy as a unique dermatosis of pregnancy [3]. Almost all reported cases of PEP have begun in the third trimester and rarely in the post-partum period [4]. A Medline search did not reveal any reported cases in non-pregnant women. In our case, the occurrence of itchy polymorphic lesions localised to the striae combined with a history of similar lesions in all previous pregnancies strongly suggests that these lesions were analogous to her previous episodes of PEP. The rapid disappearance of lesions with topical corticosteroids is also similar to the response seen in most cases of PEP. Although a biopsy could not be done in our patient, histopathological findings in cases of PEP are most often nonspecific [1]. The cause of PEP is still unknown and the only factor reported to be significantly related to its occurrence is twin pregnancy [5], due to excessive stretching of the abdominal skin, although this finding has been disputed [6]. Our patient gave a history of weight loss in the months preceding the onset of the rash, which was probably related to the cervical cancer. A recent study has implicated the phenomenon of ‘microchimerism’ in the pathogenesis of PEP [7]. Fetal DNA was detected in the epidermis of 50% and the dermis of 40% of women with PEP carrying male foetuses, but in none of the controls. It was postulated that the skin lesions may be a reaction to the presence of fetal cells in the epidermis and dermis. In another report, Bianchi et al. [8] have reported the presence of male fetal progenitor cells in maternal circulation for up to 27 years post partum. Our case may represent an analogous situation in which migration of persisting fetal cells to the skin may have elicited a PEP-like eruption 28 years after the last pregnancy. Ectopic production of human chorionic gonadotropin has also been reported in cases of carcinoma of the cervix [9], which can presumably produce a milieu resembling pregnancy thereby including PEP-like lesions. Our patient is the first reported case of recurrent PEP-like lesions in a non-pregnant woman and suggests that this dermatosis considered exclusive to the pregnancy period may rely on mechanisms developing also after delivery.

Acropigmentation of Dohi in an Indian family.

Dyschromatosis symmetrica hereditaria (DSH) is a rare, autosomally dominant genodermatosis, first reported as a clinical entity by Toyama (1, 2). This condition was described by Dohi in 1920 in 12 Japanese patients and reported later by Komaya (3) as “acropigmentation symmetrica of Dohi”. The term (reticulate) acropigmentation of Dohi is now used synonymously with DSH, more so in the Western literature (4). Apart from the skin lesions, there are no commonly associated disorders seen with acropigmentation of Dohi. We report a case associated with psoriasis. The significance of this association is also discussed. The proband was a 12 year-old Indian boy who presented with complaints of itchy, erythematous, scaly lesions over the trunk, extremities, and scalp for a duration of 8 months. On examination, these were found to be plaque-type lesions of psoriasis. In addition, he had multiple, 1–5 mm, hypopigmented and hyperpigmented macules over the hands, forearms, and below the knees on both legs (Fig. 1). These lesions had been present since infancy and had gradually increased with age. A clinical diagnosis of reticulate acropigmentation of Dohi with psoriasis was made. A punch biopsy from the hyperpigmented and hypopigmented macules revealed adjacent areas of basal hypermelanosis and hypomelanosis. This pigmentary disorder in the index case led us to the other affected members in his familyhis brother, aunt and grandmother also had had mottled pigmentation over distal parts of extremities dating back to early childhood (Fig. 2). The palms and soles were spared in all including the index case. None of the other affected members had psoriasis or any other cutaneous or systemic disease. Acropigmentation of Dohi is characterized by the distribution of hyperpigmented and hypopigmented macules on the extremities, especially over the dorsa of hands and feet. The lesions appear in infancy or early childhood over the extremities, slowly extend proximally and may affect the sides of the neck and face. The lesions are found predominantly on photo exposed areas and become more marked after sun exposure, although there is no evidence of photosensitivity. They usually stop spreading before The Journal of Dermatology Vol. 29: 386–388, 2002

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