Disseminated cryptococcus with cutaneous involvement in the setting of sarcoidosis associated CD4+...
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P6241 Delayed diagnosis of paracoccidioidomycosis: A typical case in a non- endemic area Renata Timb o, MD, Policl ınica Geral do Rio de Janeiro, Rio de Janeiro, Brazil; Erica Slaibi, MD, Hospital Geral da Santa Casa de Miseric ordia do Rio de Janeiro, Rio de Janeiro, Brazil; Jos e Augusto Nery, PhD, Fundac¸~ ao Oswaldo Cruz, Rio de Janeiro, Brazil; Luisa Kelmer, MD, Policl ınica Geral do Rio de Janeiro, Rio de Janeiro, Brazil; Marina Wermelinger, MD, Policl ınica Geral do Rio de Janeiro, Rio de Janeiro, Brazil; Renata Porphirio, MD, Universidade Est acio de S a, Rio de Janeiro, Brazil Background: Paracoccidioidomycosis (PCM), caused by the fungus Paracoccidioides brasiliensis, is the principal systemic mycosis that is autochthonous to Latin America. In Brazil, it is endemic among populations in the rural south, southeast and midwest, with 30- to 60-year-old male smokers being the most affected. According to the Ministry of Health, it is the eighth cause of death from predomi- nantly chronic conditions induced by infectious parasites and accounts for the highest mortality rate of the systemic mycoses. Infections occur from inhaling the fungus, with lungs, lymph nodes, mucosa and skin being the sites most commonly affected. The skin lesions are polymorphous, varying in color, size and appearance. They may be located on any part of the body; however, most commonly on the face and around the body’s natural orifices. Differential diagnosis is important, since PCM may mimic other diseases, both with respect to clinical and radiological characteristics. Case report: A 61-year-old male farm worker, a smoker from V arzea Alegre, Cear a who had lived for the past 16 years in southern and midwestern regions of the country, reported that at 58 years of age he developed intense dysphagia, with weight loss, coughing, exertional dyspnea, and skin and mucosal lesions, principally on the face. Based on his clinical condition and his report of having migrated from an endemic area, a diagnostic hypothesis of PCM was made after several nonconclusive tests and a 3-year delay in reaching diagnosis. Diagnosis was based on histopathology of the most recent skin lesion, where numerous budding yeast cells compatible with Paracoccidioides brasiliensis were found, some resembling a pilot wheel. Discussion: Because physicians in Cear a have little contact with the disease because of its low prevalence in the region, it is not usually taken into consideration as a diagnostic hypothesis, corroborating with errors and delays in diagnosis. Because PCM is the principal systemic mycosis in Brazil and morbidity with this disease is high, it should always be taken into consideration in differential diagnoses, even in nonendemic areas as in this case in which the patient’s epidemiological history reinforced the possibility of PCM. Timely diagnosis helps prevent an unfavorable outcome, both for the patient and for public health in general. This case highlights the importance of diagnosing typically endemic diseases occurring outside their usual regions. Commercial support: None identified. P6944 Dermatoscopy findings in tinea capitis: A case report Marina Besen Guerini, MD, private practice, Curitiba, Brazil; Debora Cadore Farias, MD, Federal University of Santa Catarina, Florian opolis, Brazil; Naiana Bittencourt de S a, MD, Private Practice, Tubarao, Brazil Background: Dermatoscopy is a method of increasing importance in the diagnoses of cutaneous diseases. Trichoscopy (hair and scalp dermatoscopy) allows identifi- cation of hair and scalp diseases such as lichen planus, psoriasis, seborrheic dermatitis, and discoid lupus, based on analysis of trichoscopy structures and patterns. Dermatoscopy can facilitates the diagnosis of tinea capitis. We describe the ‘‘comma’’ and ‘‘corkscrew hair’’dermatoscopic aspects found in a woman with tinea capitis. Case report: A 30-year-old, healthy, woman has a history of hair loss since childhood. The dermatologic examination showed diffuse rarefaction of hair and no other abnormalities. A dermatoscopy examination was performed and showed comma hairs corkscrew hairs (Figs 1 and 2). The direct mycologic examination and the culture of the collected material identified Tricophyton tonsurans. Discussion: Dermatoscopy has been used in dermatology for the identification of different structures and colors not seen by the naked eye and has been widely used in the diagnosis of pigmented lesions. Also, dermatoscopy expanded their role in the diagnosis of skin diseases as psoriasis, alopecia, parasites, nail disorders, and others. Tinea capitis is an infection of the scalp and hair caused by the dermatophytes Microsporum and Trichophyton. It is most common in infants and rare after puberty. Cases of tinea capitis in Brazil, caused by T tonsurans, occur with greater frequency in those states above the Tropic of Cancer; where fungi appear to be well adapted to the environmental conditions. It is rarely isolated in the south of Brazil. Tinea capitis can manifest with one or several areas of alopecia, with or without tonsure. The determination of a specific dermatoscopic finding could lead to a straightforward diagnosis. In 2008, Slowinska described in 2 patients with tinea capitis the presence of comma like structures (comma hair), dermatoscopic finding characterized by a pigmented, homogeneously thickened and sharp slating ended hair shaft. On dermatoscopic examination, the comma hairs and the corkscrew hairs appear to be specific dermatoscopic findings of dermatophytosis of the scalp, regardless of the etiological agent. It can facilitate the diagnosis, because it is a fast, noninvasive and inexpensive method. In this clinical case, the patient was treated for many years as an unespecific hair loss and after dermatoscopic examination we found clues to the diagnosis of tinea capitis. Commercial support: None identified. P7075 Device-based therapies for onychomycosis Aditya Gupta, MD, PhD, Mediprobe Research Inc, London, Ontario, Canada; Fiona Simpson, Mediprobe Research Inc, London, Ontario, Canada Device-based therapies are the newest and most rapidly expanding treatment modalities for onychomycosis. Traditional pharmacotherapeutics have many draw- backs including low to moderate efficacy, incomplete drug penetrance, high numbers and severity of adverse events, long treatment periods and a high patient compliance requirement. Device-based therapies are clinically administered thera- pies that diminish the need for extensive patient compliance and reduce adverse events because of their topical nature. The 3 main categories of device-based therapies are laser systems, photodynamic therapy, and iontophoresis. Laser systems treat onychomycosis through photoselective effects induced by absorption of light energy. Currently, near-infrared solid state and diode lasers are being investigated for the treatment of onychomycosis. Initial clinical studies have shown positive results for a wide variety of commercial laser models. Photodynamic therapy uses the application of a photosensitizer that is excited by red or blue light to cause apoptosis in the fungal infection. The heme precursors 5-aminolevulinic acid and methyl- aminolevulate have both been tested off-label for the treatment of onychomycosis with moderate efficacy. Syslens B is an alternative photosensitizer that has been developed in vitro for the treatment of T rubrum. Iontophoresis uses an electric current to increase the uptake of topically applied terbinafine into the nail plate, bed and matrix. There are currently 2 iontophoresis devices in development, both of which have shown initial success in small clinical trials. Device-based therapies are promising treatment modalities for onychomycosis. If subsequent clinical trials are as successful as the preliminary data for these devices, device-based therapies may provide convenient alternatives to existing pharmacotherapy. Commercial support: None identified. P6955 Disseminated cryptococcus with cutaneous involvement in the setting of sarcoidosis associated CD4 + lymphopenia Katherine Willard, MD, Mayo Clinic, Jacksonville, FL, United States; Jason Sluzevich, MD, Mayo Clinic, Jacksonville, FL, United States; Mark Cappel, MD, Mayo Clinic, Jacksonville, FL, United States Disseminated cryptococcus with cutaneous involvement is seen in patients with defects in cell-mediated immunity, particularly those with advanced AIDS, or as a complication of pharmacologic immunosuppression in organ transplant patients. Lymphopenia, including selective CD4, CD8, and CD19 deficiencies, can occur in sarcoidosis patients. We describe 2 patients with pulmonary sarcoidosis and CD4 + lymphopenia (CD4 count \100) presenting with crusted umbilicated papules and headache ultimately established to have disseminated cryptococcus. Patient 1 was a 61-year-old white man with chronic mild pulmonary sarcoidosis who presented with a severe, refractory headache of 19 days’ duration and a new waxy, crusted, skin-colored papule on the forehead. Shave biopsy revealed cutaneous cryptococ- cus. Lumbar puncture with CSF culture confirmed Cryptococcus neoformans meningitis. Peripheral blood flow cytometry revealed an absolute CD4 count of 25. HIV testing was negative. The patient was on no systemic immunosuppressant medications. Patient 2 was a 50-year-old African American male with a recent diagnosis of pulmonary sarcoidosis, on 10 mg daily of oral prednisone, with a 2- month history of waxing and waning headaches along with a progressive, friable, dome-shaped, umbilicated facial papule. Skin biopsy revealed cutaneous crypto- coccus. Cryptococcus antigen was elevated in CSF and serum. Tissue culture from the forehead lesion grew Cryptococcus neoformans. Peripheral blood flow cytom- etry was notable for a depressed CD4 count of 72. HIV testing was negative. Sarcoidosis associated lymphopenia has been attributed to an aberrant T H 1 response with sequestration of lymphocytes in sarcoidal granuloma resulting in selective immune deficits. While the morphologic spectrum of cutaneous sarcoidosis is wide, clinicians should have a high index of suspicion regarding progressive crusted papular lesions in pulmonary sarcoidosis patients, as they may be a sign of opportunistic infection, even in the absence of pharmacologic immunosuppression. Commercial support: None identified. APRIL 2013 JAM ACAD DERMATOL AB127
Transcript of Disseminated cryptococcus with cutaneous involvement in the setting of sarcoidosis associated CD4+...
P6241Delayed diagnosis of paracoccidioidomycosis: A typical case in a non-endemic area
Renata Timb�o, MD, Policl�ınica Geral do Rio de Janeiro, Rio de Janeiro, Brazil;�Erica Slaibi, MD, Hospital Geral da Santa Casa de Miseric�ordia do Rio de Janeiro,Rio de Janeiro, Brazil; Jos�e Augusto Nery, PhD, Fundac~ao Oswaldo Cruz, Rio deJaneiro, Brazil; Luisa Kelmer, MD, Policl�ınica Geral do Rio de Janeiro, Rio deJaneiro, Brazil; Marina Wermelinger, MD, Policl�ınica Geral do Rio de Janeiro, Riode Janeiro, Brazil; Renata Porphirio, MD, Universidade Est�acio de S�a, Rio deJaneiro, Brazil
Background: Paracoccidioidomycosis (PCM), caused by the fungusParacoccidioidesbrasiliensis, is the principal systemic mycosis that is autochthonous to LatinAmerica. In Brazil, it is endemic among populations in the rural south, southeastand midwest, with 30- to 60-year-old male smokers being the most affected.According to the Ministry of Health, it is the eighth cause of death from predomi-nantly chronic conditions induced by infectious parasites and accounts for thehighest mortality rate of the systemic mycoses. Infections occur from inhaling thefungus, with lungs, lymph nodes, mucosa and skin being the sites most commonlyaffected. The skin lesions are polymorphous, varying in color, size and appearance.They may be located on any part of the body; however, most commonly on the faceand around the body’s natural orifices. Differential diagnosis is important, since PCMmay mimic other diseases, both with respect to clinical and radiologicalcharacteristics.
Case report: A 61-year-old male farm worker, a smoker from V�arzea Alegre, Cear�awho had lived for the past 16 years in southern and midwestern regions of thecountry, reported that at 58 years of age he developed intense dysphagia, withweight loss, coughing, exertional dyspnea, and skin and mucosal lesions, principallyon the face. Based on his clinical condition and his report of having migrated from anendemic area, a diagnostic hypothesis of PCMwas made after several nonconclusivetests and a 3-year delay in reaching diagnosis. Diagnosis was based on histopathologyof the most recent skin lesion, where numerous budding yeast cells compatible withParacoccidioides brasiliensis were found, some resembling a pilot wheel.
Discussion: Because physicians in Cear�a have little contact with the disease becauseof its low prevalence in the region, it is not usually taken into consideration as adiagnostic hypothesis, corroborating with errors and delays in diagnosis. BecausePCM is the principal systemic mycosis in Brazil and morbidity with this disease ishigh, it should always be taken into consideration in differential diagnoses, even innonendemic areas as in this case in which the patient’s epidemiological historyreinforced the possibility of PCM. Timely diagnosis helps prevent an unfavorableoutcome, both for the patient and for public health in general. This case highlightsthe importance of diagnosing typically endemic diseases occurring outside theirusual regions.
APRIL 20
cial support: None identified.
CommerP6944Dermatoscopy findings in tinea capitis: A case report
Marina Besen Guerini, MD, private practice, Curitiba, Brazil; Debora CadoreFarias, MD, Federal University of Santa Catarina, Florian�opolis, Brazil; NaianaBittencourt de S�a, MD, Private Practice, Tubarao, Brazil
Background: Dermatoscopy is a method of increasing importance in the diagnosesof cutaneous diseases. Trichoscopy (hair and scalp dermatoscopy) allows identifi-cation of hair and scalp diseases such as lichen planus, psoriasis, seborrheicdermatitis, and discoid lupus, based on analysis of trichoscopy structures andpatterns. Dermatoscopy can facilitates the diagnosis of tinea capitis. We describe the‘‘comma’’ and ‘‘corkscrew hair’’ dermatoscopic aspects found in a woman with tineacapitis.
Case report: A 30-year-old, healthy, woman has a history of hair loss since childhood.The dermatologic examination showed diffuse rarefaction of hair and no otherabnormalities. A dermatoscopy examination was performed and showed commahairs corkscrew hairs (Figs 1 and 2). The direct mycologic examination and theculture of the collected material identified Tricophyton tonsurans.
Discussion: Dermatoscopy has been used in dermatology for the identification ofdifferent structures and colors not seen by the naked eye and has been widely usedin the diagnosis of pigmented lesions. Also, dermatoscopy expanded their role in thediagnosis of skin diseases as psoriasis, alopecia, parasites, nail disorders, and others.Tinea capitis is an infection of the scalp and hair caused by the dermatophytesMicrosporum and Trichophyton. It is most common in infants and rare after puberty.Cases of tinea capitis in Brazil, caused by T tonsurans, occur with greater frequencyin those states above the Tropic of Cancer; where fungi appear to be well adapted tothe environmental conditions. It is rarely isolated in the south of Brazil. Tinea capitiscan manifest with one or several areas of alopecia, with or without tonsure. Thedetermination of a specific dermatoscopic finding could lead to a straightforwarddiagnosis. In 2008, Slowinska described in 2 patients with tinea capitis the presenceof comma like structures (comma hair), dermatoscopic finding characterized by apigmented, homogeneously thickened and sharp slating ended hair shaft. Ondermatoscopic examination, the comma hairs and the corkscrew hairs appear to bespecific dermatoscopic findings of dermatophytosis of the scalp, regardless of theetiological agent. It can facilitate the diagnosis, because it is a fast, noninvasive andinexpensive method. In this clinical case, the patient was treated for many years asan unespecific hair loss and after dermatoscopic examination we found clues to thediagnosis of tinea capitis.
cial support: None identified.
Commer13
P7075Device-based therapies for onychomycosis
Aditya Gupta, MD, PhD, Mediprobe Research Inc, London, Ontario, Canada;Fiona Simpson, Mediprobe Research Inc, London, Ontario, Canada
Device-based therapies are the newest and most rapidly expanding treatmentmodalities for onychomycosis. Traditional pharmacotherapeutics have many draw-backs including low to moderate efficacy, incomplete drug penetrance, highnumbers and severity of adverse events, long treatment periods and a high patientcompliance requirement. Device-based therapies are clinically administered thera-pies that diminish the need for extensive patient compliance and reduce adverseevents because of their topical nature. The 3 main categories of device-basedtherapies are laser systems, photodynamic therapy, and iontophoresis. Laser systemstreat onychomycosis through photoselective effects induced by absorption of lightenergy. Currently, near-infrared solid state and diode lasers are being investigated forthe treatment of onychomycosis. Initial clinical studies have shown positive resultsfor a wide variety of commercial laser models. Photodynamic therapy uses theapplication of a photosensitizer that is excited by red or blue light to cause apoptosisin the fungal infection. The heme precursors 5-aminolevulinic acid and methyl-aminolevulate have both been tested off-label for the treatment of onychomycosiswith moderate efficacy. Syslens B is an alternative photosensitizer that has beendeveloped in vitro for the treatment of T rubrum. Iontophoresis uses an electriccurrent to increase the uptake of topically applied terbinafine into the nail plate, bedand matrix. There are currently 2 iontophoresis devices in development, both ofwhich have shown initial success in small clinical trials. Device-based therapies arepromising treatment modalities for onychomycosis. If subsequent clinical trials areas successful as the preliminary data for these devices, device-based therapies mayprovide convenient alternatives to existing pharmacotherapy.
cial support: None identified.
CommerP6955Disseminated cryptococcus with cutaneous involvement in the setting ofsarcoidosis associated CD4+ lymphopenia
Katherine Willard, MD, Mayo Clinic, Jacksonville, FL, United States; JasonSluzevich, MD, Mayo Clinic, Jacksonville, FL, United States; Mark Cappel, MD,Mayo Clinic, Jacksonville, FL, United States
Disseminated cryptococcus with cutaneous involvement is seen in patients withdefects in cell-mediated immunity, particularly those with advanced AIDS, or as acomplication of pharmacologic immunosuppression in organ transplant patients.Lymphopenia, including selective CD4, CD8, and CD19 deficiencies, can occur insarcoidosis patients. We describe 2 patients with pulmonary sarcoidosis and CD4+
lymphopenia (CD4 count\100) presenting with crusted umbilicated papules andheadache ultimately established to have disseminated cryptococcus. Patient 1 was a61-year-old white man with chronic mild pulmonary sarcoidosis who presentedwith a severe, refractory headache of 19 days’ duration and a new waxy, crusted,skin-colored papule on the forehead. Shave biopsy revealed cutaneous cryptococ-cus. Lumbar puncture with CSF culture confirmed Cryptococcus neoformansmeningitis. Peripheral blood flow cytometry revealed an absolute CD4 count of 25.HIV testing was negative. The patient was on no systemic immunosuppressantmedications. Patient 2 was a 50-year-old African American male with a recentdiagnosis of pulmonary sarcoidosis, on 10 mg daily of oral prednisone, with a 2-month history of waxing and waning headaches along with a progressive, friable,dome-shaped, umbilicated facial papule. Skin biopsy revealed cutaneous crypto-coccus. Cryptococcus antigen was elevated in CSF and serum. Tissue culture fromthe forehead lesion grew Cryptococcus neoformans. Peripheral blood flow cytom-etry was notable for a depressed CD4 count of 72. HIV testing was negative.Sarcoidosis associated lymphopenia has been attributed to an aberrant TH1 responsewith sequestration of lymphocytes in sarcoidal granuloma resulting in selectiveimmune deficits. While the morphologic spectrum of cutaneous sarcoidosis is wide,clinicians should have a high index of suspicion regarding progressive crustedpapular lesions in pulmonary sarcoidosis patients, as they may be a sign ofopportunistic infection, even in the absence of pharmacologic immunosuppression.
cial support: None identified.
CommerJ AM ACAD DERMATOL AB127
