P6628Mites and burrows are frequently found in nodular scabies by dermatos-copy and histopathology

Min Soo Jang, MD, Department of Dermatology, Kosin University College ofMedicine, Busan, South Korea; Dong Young Kang, MD, Department ofDermatology, Kosin University College of Medicine, Busan, South Korea; JongBin Park, MD, Department of Dermatology, Kosin University College of Medicine,Busan, South Korea; Kee Suck Suh, MD, Department of Dermatology, KosinUniversity College of Medicine, Busan, South Korea; Sang Hwa Han, MD,Department of Dermatology, Kosin University College of Medicine, Busan,South Korea; Sang Tae Kim, MD, Department of Dermatology, Kosin UniversityCollege of Medicine, Busan, South Korea

Nodular scabies is a clinical variant of classic scabies with uncertain cause, whichpresents with pruritic, erythematous nodules, especially on the axillae, groin, andgenitalia, such as the scrotum. Although nodules of scabies were thought to resultfrom persisting antigens (mites, egg, and excretas), mites were seldom found in thenodules. Earlier studies have shown that mites and mite parts are generally absentfrom scabietic nodules. Thus, scabietic nodules are regarded to be caused by anexaggerated hypersensitivity reaction to the female mite, its eggs and scybala, ratherthan by an active infection. Dermatoscopy allows one to see surface and subsurfaceskin structures not easily detected by the naked eye. Moreover, unique dermato-scopic findings such as jet with condensation trails are considered as specificfeatures in scabies. Histopathologic examination of a nodule appears to be alsouseful to diagnose nodular scabies and serial sections may be necessary to detect themite. We were able to find the mites and burrows in 6 consecutive cases bydermatoscopy and histopathological examination, despite nodular scabies. In thisrespect, we suggest that scabietic nodules are regarded to be caused by an activeinfection rather than by a hypersensitivity reaction.

APRIL 20

cial support: None identified.

Commer

P6616Mycetoma: A therapeutic challenge

Norma Alejandra Gonz�alez, MD, Hospital Universitario Dr. Jos�e EleuterioGonz�alez, Monterrey, Mexico; Alejandra Villarreal, MD, Hospital UniversitarioDr. Jos�e Eleuterio Gonz�alez, Monterrey, Mexico; Cristina Cant�u, MD, HospitalUniversitario Dr. Jos�e Eleuterio Gonz�alez, Monterrey, Mexico; Jorge Ocampo,Hospital Universitario Dr. Jos�e Eleuterio Gonz�alez, Monterrey, Mexico; OliverioWelsh, MD, PhD, Hospital Universitario Dr. Jos�e Eleuterio Gonz�alez, Monterrey,Mexico

Background: Mycetoma is a chronic and progressive disease that involves subcuta-neous tissue and organs. It is caused by fungi and aerobic Gram-positive bacilli(98%). In Mexico, the most common causative agent is Nocardia brasiliensis(86.6%) followed by Actinomadura madurae (9.6%). The classical N brasiliensislesions involve the lower extremities with swelling, abscesses, and fistulas. Therapyincludes sulfonamides, trimethoprim-sulfamethoxazole, imipenem and amoxicillin-clavulanic acid. The high incidence of resistance makes it a therapeutic challenge.

Case report: A 33-year-old man, farmer; with a history of untreated paranoidschizophrenia. He began his current condition 5 years after suffering penetratingtrauma in his right lower extremity. Presenting asymptomatic nodules, whichincreased in size and number in an ascending manner causing deterioration in hisability to deambulate. He denied previous treatment. Physical examination revealednodules, fistulas and abscesses, hyperchromic and indurated skin in his right lowerlimb. He was admitted for treatment. Initial laboratories showed thrombocytosis(1061 U/�L); direct examination of the skin lesion (KOH) was positive to Nbrasiliensis; HP: abscessed and ulcerated acute and chronic inflammatory changeswith negative PAS and ZiehleNeelsen, IgG specific positive to N brasiliensis;negative HIV; MRI: destruction of tissue with osteomyelitis (tarsus, metatarsus, tibiaand fibula). Treatment was started with 4 21-day cycles of amikacin 750 mg per day(baseline audiogram and after each cycle, with no alterations), trimethoprim 160mg/sulfamethoxazole 800 mg twice daily and imipenem 500 mg 4 times daily. Hewas discharged 3 months after admission with trimethoprim 160 mg/sulfamethox-azole 800 mg PO twice daily, completing 10 months of treatment, being able todeambulate with significant improvement in his quality of life.

Conclusion: N brasiliensis inoculation after a trauma is very common in ourenvironment. This is a public health issue that is sometimes underdiagnosed andundertreated. It is imperative to make an early diagnosis and timely and to initiateappropriate antibiotic scheme.

cial support: None identified.

Commer

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P5908Mycobacteria mucogenicum infection following a cosmetic procedurewith poly-L-lactic acid

Ralph Fiore II, DO, Largo Medical Center, Largo, FL, United States; Richard Miller,DO, Largo Medical Center, Largo, FL, United States; Sarah Coffman, DO, MMSc,Largo Medical Center, Largo, FL, United States

The preservation of youth is ever apparent as new antiaging products, cosmeticprocedures and advertising campaigns aim to address new ways to prevent thenatural aging process. Many individuals prefer noninvasive surgical proceduresinvolving minimal downtime and a speedy recovery. Although these cosmeticprocedures are considered minor, complications do arise and infections can occur.While many species of bacteria can cause these infections, one such species that isusually over looked and can cause these infections are the atypical Mycobacteria.Early diagnosis is important because these infections can rapidly progress into moreserious skin manifestations. We present a 31-year-old woman with a 3-month historyof a nonhealing ulcer on her cheek that started approximately 2 weeks after acosmetic procedure with an injectable filler. This patient represents an uncommoncomplication that may occur in patients subjected to multiple facial injections,because secondary biofilm formation increases with their current and futureinjections. This case review highlights the growing number of cosmetic proceduresin our society, the most common complications of these treatments, an emergingcomplication concerning the formation of biofilms, as well as a review of theliterature on atypical mycobacteria infections.

cial support: None identified.

Commer

P6398Mycobacterium abscessus infection occurring within lesions of goutytophi

Uma Alagappan, MD, Changi General Hospital, Singapore; Helen May-Lin Oh,MD, Changi General Hospital, Singapore; Mark Jean-Aan Koh, MD, ChangiGeneral Hospital, Singapore

A 61-year-old Chinese man presented with a 2-month history of progressive,multiple, painful, ulcerated nodules and papules on his left lower leg. He had ahistory of myasthenia gravis, for which he was on long-term oral prednisolone. Onexamination, some of the nodules had a chalky material extruding from theulcerated surface. Incisional biopsy showed focal large deposits of amorphous,eosinophilic material in the dermis, consistent with gouty tophi. Aerobic bacterialand AFB cultures from the biopsy site were positive forMabscessus. The patient wastreated with 2 months of oral azithromycin, with resolution of lesions. Cutaneousdisease caused by M abscessus can follow 2 patterns, dependant on the patient’simmune status. Infections in immunocompetent hosts commonly present aslocalized cellulitis or abscesses after trauma or inoculation with contaminatedneedles. In immunocompromised hosts, a history of trauma may not be evident anddisseminated cutaneous infection is more common. Although our patient had ahistory of gout, he could not recall the presence of tophi on his left leg before thedevelopment of the discharging abscesses. It cannot be ascertained for certain if thegouty tophi was an entry point for M abscessus or did it develop secondary toinflammation generated by the bacterium. Treatment of M abscessus infection isdifficult, because the bacterium is not susceptible to the usual antituberculousdrugs, as well as other common antibiotics. Factors responsible for the naturalresistance of M abscessus to many antibiotics include its slow growth, presence ofan impermeable cell wall, efflux pumps and antibiotic modifying or inactivatingenzymes. In conclusion, we described a rare and interesting case of an immunosup-pressed patient who presented with cutaneous M abscessus infection occurringconcomitantly with lesions of gouty tophi. The case also underlies the importance ofsending tissue specimens for mycobacterial cultures, in addition to routine histol-ogy, when there is a high index of suspicion for chronic mycobacterial infection.

cial support: None identified.

Commer

J AM ACAD DERMATOL AB121