Stefano Ramoni

Amicrobial pustulosis of the folds: Report of 6 cases and a literature review

Background: Amicrobial pustulosis of the folds (APF) is a rare entity characterized by relapsing pustular lesions involving mainly the cutaneous folds. The disease typically occurs in the context of an autoimmune disorder and is classified within the spectrum of neutrophilic dermatoses. Objective: We studied 6 young females having APF associated with various autoimmune diseases or with the presence of serum autoantibodies and reviewed the literature, in order to give a clinical overview on this syndrome. Methods: Various routine and immunological laboratory tests, histopathological examination as well as direct and indirect immunofluorescence examinations were performed. In vitro neutrophil function was evaluated in 5 cases. We report our findings and compare our cases with those published in the literature. Results: Clinically, at least one major fold and at least one minor fold as well as the anogenital area were always involved. We documented an impaired neutrophil chemotaxis in 2 subjects, neutrophil dysfunction, thus failing to be a verifying criterion. Conclusion: APF is a neutrophilic dermatosis affecting young females, which usually shows a benign clinical behavior. Although systemic corticosteroids are the most widely used therapeutic agents, we suggest that the combination of cimetidine and ascorbic acid represents a safe alternative, which may induce long-lasting clinical remission.

Leflunomide-induced subacute cutaneous lupus erythematosus with erythema multiforme-like lesions

Leflunomide is an immunosuppressive agent that acts by inhibiting pyrimidine synthesis in lymphocytes and other rapidly proliferating cells, as well as by suppressing tumor necrosis factor-α–induced cellular responses. A number of leflunomide-related adverse events have been reported. Among cutaneous side effects, a few cases of subacute cutaneous lupus erythematosus have been described. We report a previously undocumented reaction to leflunomide, manifesting as subacute cutaneous lupus erythematosus and erythema multiforme-like lesions, in a young woman treated with this drug for ankylosing spondylitis. Withdrawal of leflunomide combined with a short cycle of systemic corticosteroid led to the resolution of the patient’s rash, indicating this drug as being responsible for the development of the disease. We conclude that leflunomide might have triggered the occurrence of both subacute cutaneous lupus erythematosus and erythema multiforme in a patient with pre-existing autoimmune diathesis. The suppressive effect of this drug on tumor necrosis factor-α–related mechanisms might have played a role in the induction of such a unique reaction to leflunomide.

Syphilitic chancres of the mouth: three cases.

Part 3, chapter 16. In: An illustrated guide to skin lymphoma. 2nd edn. Oxford: Blackwell Publishing Ltd; 2004, p. 133-137. 3. PetrellaT, Bagot M, Willemze R, Beylol-Barry M. Vergier B. Delaunay M, et a!. Blastic NK-cell lymphomas (agranular CD4+ CD56+ hematodermic neoplasms). Am J Clin Pathol 2005;123:662-675. 4. Adachi M, Maeda K, Takekawa M. Hinoda Y. Imai K, Sugiyama S. et al. High expression of CD56 (N ¡82CAM) in patient with cutaneous CD4-posÍtive lymphoma. Am J Hematol 1994; 47: 278-282. 5.Niakosari F, Sur M. Angular CD+/CD56+ hematodermic neoplasm. A distinct entity described in the recent World Health Organization-European Organization for Research and Treatment of Cancer Classification for Cutaneous Lymphomas. Arch Pathol Lab Med 2007: 131: 149-151. 6. Kato N, Yasukawa K, Kimura K, Sugawara H, Aoyagi S, Mishina T, et al. CD2-CD4+CD56+ hematodermic/hematolymphoid malignancy malignancy. J Am Acad Dermatol 2001:44:231-238. 7. Willemze R, Jaffe ES, Burg G. Cerroni L, Berti E, Swerdlow SH. et al. WHO-EORTC classification for cutaneous lymphoma. Blood 2005; 105: 3768-3785. 8. Chan JK, Sin VC. Wong KF, Ng CS, Tsang WY, Chan CH, et al. Nonnasal lymphoma expressing the natural killer cell marker CD56: a clinicopathologic study of 49 cases of an uncommon aggressive neoplasm. Blood 1997; 89: 4501^513.

Enhanced molecular typing of treponema pallidum subspecies pallidum strains from 4 Italian hospitals shows geographical differences in strain type heterogeneity, widespread resistance to macrolides, and lack of mutations associated with doxycycline resistance

Background Although syphilis rates have been relatively high in Italy for more than 15 years, no data on the molecular types of Treponema pallidum subspecies pallidum circulating in this country are yet available. Likewise, no data on how widespread is resistance to macrolide or tetracycline antibiotics in these strains exist. Such data would, however, promote comprehensive studies on the molecular epidemiology of syphilis infections in Italy and inform future interventions aiming at syphilis control in this and other European countries. Goals and Study Design Swabs from oral, genital, cutaneous, or anal lesions were obtained from 60 syphilis patients attending dermatology clinics in Milan, Turin, Genoa, and Bologna. Molecular typing of T. pallidum DNA was performed to provide a snapshot of the genetic diversity of strains circulating in Northern Italy. Samples were also screened for mutations conferring resistance to macrolides and tetracyclines. Results T. pallidum DNA was detected in 88.3% (53/60) of the specimens analyzed. Complete and partial T. pallidum typing data were obtained for 77.3% (41/53) and 15.0% (8/53) of samples, respectively, whereas 4 samples could not be typed despite T. pallidum DNA being detected. The highest strain type heterogeneity was seen in samples from Bologna and Milan, followed by Genoa. Minimal diversity was detected in samples from Turin, despite the highest number of typeable samples collected there. Resistance to macrolides was detected in 94.3% (50/53) of the strains, but no known mutations associated with tetracycline resistance were found. Conclusions Genetic diversity among T. pallidum strains circulating in Northern Italy varies significantly among geographical areas regardless of physical distance. Resistance to macrolides is widespread.

Rapidly Invasive Buschke-Löwenstein Tumor Associated With Human Papillomavirus Types 6 and 52.

Buschke-Löwenstein tumor, or giant condyloma acuminatum, represents a rare, sexually transmitted disorder, with a slow evolution and the tendency to infiltrate in the adjacent tissues associated with human papillomavirus (HPV). This article reports the first case of male Buschke-Löwenstein tumor associated with HPV6 and HPV52.

Secondary syphilis masquerading as lupus vulgaris in an HIV-infected patient: A diagnosis suggested by histology

We report a case of secondary syphilis mimicking lupus vulgaris in an HIV-infected patient. A 21-year-old Brazilian man presented with a two-month history of asymptomatic cutaneous lesions accompanied by fever and fatigue. Dermatological evaluation revealed an erythematous, crusted, large plaque on the neck with the ‘apple jelly’ sign on diascopy and two smaller scaly elements on the trunk and left palm. Bacteriological examinations for bacteria and mycobacteria gave negative results. Histology revealed psoriasiform epidermal hyperplasia and dermal lymphoplasmacytic infiltrate. Serology for syphilis was positive, and immunohistochemistry confirmed the presence of Treponema pallidum in lesional skin. A diagnosis of secondary syphilis was made, and the patient was successfully treated with benzathine penicillin G. Cutaneous manifestations of secondary syphilis are protean and skin tuberculosis may be considered in the differential diagnosis, especially in HIV-infected patients. In the current case, clinical examination, and particularly, ‘apple jelly’ sign positivity, was suggestive of lupus vulgaris, but only typical histopathology and immunohistochemistry led to the correct diagnosis of secondary syphilis.

Chronic Nodular Dermatosis: A Quiz

A 29-year-old Egyptian man presented with a 6-month history of multiple papular nodular lesions on his limbs. Prior to admission to our department he had been treated with topical antibiotics and corticosteroids by other specialists, but with no resolution. On admission, he had multiple brownish papular nodular lesions, some with erosions and other with crusts, on his legs (Fig. 1a), and an erythematous ulcerated plaque on his left wrist (Fig. 1b). In addition, some slightly erythematous firm nodules were present on his face (Fig. 1c). The patient’s general condition was noncompromised, he only reported mild itching. He worked as a warehouseman at the vegetable market in Milan and had been in Italy permanently for 2 years. Serology for HIV and syphilis were negative. Neurological examination documented a loss of sensation in the lesions on the lower limbs, with no palpable nerve enlargement. Biopsy specimens from the plaque on the left wrist were submitted for histology (Fig. 1d).

Sudden Genital Ulceration in a Young Man: A Quiz

A 24-year-old circumcised man presented with an ulcerative lesion on the penis which had been present for 3 days. He reported that the lesion had appeared after sexual intercourse with his girlfriend. He had been circumcised in childhood for religious reasons. Clinical examination revealed an ulcerative and crusted posthitis with multiple ulcers, penile oedema and bilateral inguinal lymphadenopathy (Fig. 1). The patient reported having fever and malaise. Cutaneous swabs for herpes simplex virus types 1 and 2, Treponema pallidum and Chlamydia trachomatis PCR were negative, whereas cutaneous swab for bacterial culture detected Streptococcus pyogenes and Staphylococcus aureus. Serological tests for syphilis, HIV and hepatitis C virus were negative. Systemic therapy with ceftriaxone, 1 g i.m. for 5 days, was prescribed, which resulted in improvement in the ulcerative lesions and general symptoms, but hard penile oedema was still present. The patient denied any aberrant sexual activity or other sexual practices, even upon further questioning. The personal history of the otherwise healthy patient was inconspicuous. A biopsy from the thick portion on the penis was performed.

Contents Vol. 216, 2008

S.M. Aiba, Sendai S. Chimenti, Rome O. Chosidow, Paris B. Cribier, Strasbourg M.A. De Rie, Amsterdam C. Gelmetti, Milano E. Grosshans, Strasbourg K. Holubar, Vienna H. Hönigsmann, Vienna P. Joly, Rouen S. Karpati, Budapest A.D. Katsambas, Athens J.-M. Lachapelle, Brussels H.I. Maibach, San Francisco, Calif. J.M. Mascaro, Barcelona M.C. Mihm, Jr., Boston, Mass. G.E. Piérard, Liège G. Plewig, Munich F.C. Powell, Dublin A.-A. Ramelet, Lausanne J. Revuz, Créteil J. Ring, Munich M. Röcken, Tübingen R.A. Schwartz, Newark, N.J. N. Stavrianeas, Athens H. Traupe, Münster A. Vahlquist, Uppsala D.T. Woodley, Los Angeles, Calif. Offi cial Organ of