Disseminated Mycobacterium chelonae infection in a patient with relapsing polychondritis

Disseminated Mycobacterium chelonae infection in a patient with relapsing polychondritis

P6001 P6416 Demodicosis: Clinical, dermatoscopic, and microscopic correlation Abigail Donnelly, MD, Mayo Clinic, Scottsdale, AZ, United States; Ange...

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Demodicosis: Clinical, dermatoscopic, and microscopic correlation Abigail Donnelly, MD, Mayo Clinic, Scottsdale, AZ, United States; Angela Kenney, PA, Mayo Clinic, Scottsdale, AZ, United States; David DiCaudo, MD, Mayo Clinic, Scottsdale, AZ, United States; David Swanson, MD, Mayo Clinic, Scottsdale, AZ, United States

Difficulty in diagnosing childhood leprosy Luisa Kelmer-Silveira, MD, Policlınica Geral do Rio de Janeiro, Rio de Janeiro, Brazil; Felipe Ladeira, MD, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa de Misericordia do Rio de Janeiro, Rio de Janeiro, Brazil; Marina Wermelinger, MD, Policlınica Geral do Rio de Janeiro, Rio de Janeiro, Brazil; Renata Timb o, MD, Policlınica Geral do Rio de Janeiro, Rio de Janeiro, Brazil

Demodicosis is the term applied to a variety of skin diseases caused by demodex mites. Although they are felt to be commensal organisms of the pilosebaceous units of the face, scalp, and chest, Demodex folliculorum and D brevis have been implicated in papulopustular rosacea, perioral dermatitis, and other papulopustular eruptions. Often overlooked in the differential diagnosis of chronic, pruritic eruptions of sebaceous skin, the increasing use of dermatoscopy in regular clinical examination offers a potential new option for rapid diagnosis of this infestation. Herein we describe a case of facial demodicosis and its response to treatment, and newly describe the dermatoscopic features of demodicosis. A 28 year-old Iranian man with a several-year history of a pruritic, progressive rash involving the bearded face and temporal scalp presented for evaluation. He stated the eruption began as a single red spot in his beard for which he sought evaluation from numerous dermatologists. Previous unsuccessful therapies included courses of prednisone, antifungal creams, topical corticosteroids, and selenium-containing shampoo. Previous patch testing revealed sensitivity to thimerosal #23, which he subsequently avoided with no improvement. Physical examination revealed poorly marginated red patches surmounted by fine white scale on the bilateral cheeks and temples and diffusely throughout the beard. Greasy, yellowish scale was noted throughout the scalp. Dermatoscopic examination revealed blotchy milky red erythema, white scale and innumerable perifollicular and non-follicle based tapered yellowish filaments. At follicular ostia numerous filaments were identified protruding from a single opening. Potassium hydroxide preparation of skin scrapings from the cheek revealed multiple viable demodex mites. The patient was instructed to perform 3 12-hour applications of permethrin 5% cream to the entire face 7 days apart. Within 6 weeks of this treatment, the patient reported significant improvement in erythema and scale. Demodicosis should be considered in the differential diagnosis of recurrent or recalcitrant dermatitic or rosacea-like eruptions in a seborrheic distribution. Detection of numerous tapered yellowish filaments within a field of erythema, pruritus, or scale should prompt clinicians to investigate further for demodicosis. This case is reported for its novel dermatoscopic description of a common infestation. Commercial support: None identified.

Background: Leprosy is a public health issue in Brazil that also affects the pediatric age group. The objective of the present study was to call attention to the difficulty experienced by health care professionals when diagnosing childhood leprosy. Case report: Y.G.F.R., a 6-year old girl born in Rio de Janeiro and living in Mage, presented with hypochromic skin lesions that had first been detected 1 year previously. Her mother had been irregularly treated for tuberculoid leprosy and reported that earlier the child had been diagnosed and treated for pityriasis versicolor. Physical examination showed a BCG scar, clearly outlined, infiltrated, hypochromic plaques on her face and hypochromic macules on her upper limbs and lower right limb. She weighed 20 kg. Altered sensibility was detected using ether. In view of the epidemiological association, the fact that the lesions were suggestive of leprosy and the altered sensibility, a diagnosis of paucibacillary leprosy of the borderline tuberculoid type was made. Multidrug therapy was initiated with pediatric doses in accordance with the patient’s weight. Discussion: Diagnosing leprosy in childhood when it is not the nodular form of the disease may be difficult, particularly in undetermined or dimorphous cases (borderline tuberculoid leprosy) due to the large number of lesions. Childhood leprosy is a benign variant of tuberculoid leprosy that generally affects children of 2 to 4 years of age who have been in protracted contact with bacilliferous patients. For a long time, it was believed that this was the only childhood form of the disease. Diagnosis is eminently clinical and it is important to emphasize that, of the dermatologic diseases that constitute possible differential diagnoses (eg, pityriasis versicolor and vitiligo), leprosy is the only one that causes alterations in sensibility and furthermore there is almost always an important epidemiologic history. The course of untreated leprosy in children is unpredictable and may progress to complete remission with no treatment whatsoever or generate severe sequelae if untreated due to delayed diagnosis. The majority of the primary health care professionals working in the public network in Brazil do not have the experience necessary to perform a correct and timely diagnosis in this age group, affecting the natural history of the disease, permitting its dissemination and the development of sequelae that may be incapacitating. Commercial support: None identified.

P6792 Diagnosis of late multibacillary leprosy endemic country: Keeping still endemic? Maria Vict oria Quaresma, MD, IDPRDA - Instituto de Dermatologia Professor Rubem David Azulay, RIO DE JANEIRO, Brazil; Camila Sanches Bussad, IDPRDA Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro, Brazil; Fred Bernardes Filho, MD, IDPRDA - Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro, Brazil; Mariana de Campos Raze, IDPRDA - Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro, Brazil; Marina de Campos Raze, IDPRDA - Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro, Brazil; Renata Porphirio, IDPRDA - Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro, Brazil; Renata Pinto Fernandes Timb o, IDPRDA - Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro, Brazil

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Discussion: It is imperative that patients are aware of the signs and symptoms of the disease in order to self-examine, and diagnosis can be performed in an early stage of the disease, thereby avoiding sequelae. The longer the delay to diagnoses, more sequalae are possible. It is important to conduct educational campaigns and search actively for cases, promoting knowledge about the disease and treatment. Effective control of disease, however, challenges the organization of health services and requires social mobilization, because of the long incubation period, the high number of cases, the stigma that determines the disease, and the consequences that some patients may develop. With this awareness, it seems necessary to develop integrated control actions, in partnership with the local health, education, and social authorities, in an attempt to establish a surveillance system that allows early detection and treatment of new cases. The active search has proved to be an effective method for the detection of cases, and has made possible the various sectors of society further clarification about the disease and its determinants.

Disseminated Mycobacterium chelonae infection in a patient with relapsing polychondritis Carol Cunningham, MBBCh, Salford Royal Foundation Trust, Manchester, United Kingdom A 67-year-old woman with a 15-year history of relapsing polychondritis (RP) presented with a 2-year history of extensive, firm, subcutaneous nodules and plaques, new-onset small joint arthralgia and fatigue. She denied weight loss/night sweats or fever. She had no history of preceding skin trauma or invasive procedures. She had been on long term immunosuppression for RP, and at presentation she had been taking oral prednisolone long term and more recently methotrexate and adalimumab. Initial lesions which developed on legs and dorsum of nose were diagnosed as superficial bacterial infection and treated with antibiotics with some improvement. Six months later, she presented with extensive and suppurative erythematous/violaceous, firm/fluctulant subcutaneous nodules (some ulcerated) on face and limbs. The differential diagnosis included subcutaneous infection/panniculitis, Sweet syndrome, and sarcoidosis. Two deep skin biopsies showed subcutis infilitrated by macrophages and eosinophils consistent with lobular granulomatous panniculitis and containing acid fast bacilli (basophilic beaded branching organisms). Tissue cultures grew Mycobacterium chelonae. Methotrexate was withdrawn and prednisolone slowly weaned without an associated flare of RP. Treatment consisted of combined azithromycin, clofazimine, linezolid and ethambutol and her general health and arthralgia improved. Cutaneous nodules resolved slowly and RP remains in remission. M chelonae is a ubiquitous, rapidly growing nontuberculous mycobacterium (NTM) which occurs as a skin commensal. Cutaneous infection is rare and may present as papules/nodules/plaques/abscesses/verrucous lesions/ulcers or in a sporotrichoid configuration. Skin biopsy typically demonstrates neutrophils and abscesses within the dermis/subcutis and may contain granulomas with/without necrosis. This is in contrast to our case in which there was a more chronic inflammatory response—a feature which has not been emphasized in the literature to date. Disseminated infection tends to occur in immunocompromised patients. In one case series by Wallace et al, 62% of patients with M chelonae infection of skin/soft tissue had received long term prednisolone. Associations with adalimumab and methotrexate treatment have also been reported. Treatment of atypical mycobacteria, including M chelonae, is challenging because of multiple drug resistance and prognosis is worse if immunosuppression is continued.

Commercial support: None identified.

Commercial support: None identified.

Background: Leprosy is a slow and chronic infectious disease, known as Hansen disease, caused by Mycobacterium leprae. Is an important public health problem in Brazil, the second country in number of cases in the world after India, accounting for 94% of new cases detected in the Americas. As result, it is of great importance to perform national campaigns to actively search for infected patients in order to locate, quantify and identify new cases of the disease, in search to prevent and combat the disease. Case report: Male patient, 36 years, coming from Rio de Janeiro, construction worker. In a national campaign, was suspected to have multibacillary leprosy and referred to a especialized dermatology center. His complaints was that about a year ago he noticed hyperchromic macules appearing in the right arm that progressed to the trunk and lower limbs, sugestive of erythema nodosum. On physical examination, there were hyperchromic macules on the trunk, nodular lesions on upper and lower limbs with paresthesia in the lower limbs, the presence of madarosis and leonine facies. After positive dermatologic shaving, he was diagnosed with lepromatous leprosy. Began treatment immediately PCT-MB and 100 mg thalidomide for the treatment of erythema nodosum.

APRIL 2013

J AM ACAD DERMATOL

AB117