Saturday, November 24, 2012

Facial Lesion in a Child

Case presented by Dr Munqithe M Jabir, Addiwaniya, Iraq who writes:
"Can I please have your opinion about this problematic case.
The patient is a female child with a swelling on her left cheek for the past three months.  It discharges pus through many openings (carbuncle-like!!).  There has been no change although many courses of different antibiotics, but, recently it has responded slowly to Rifampicin 150mg twice daily and Clarithromycin 250 mg twice daily.  Complete blood picture and ESR are normal."

Here is a Video. 
1. Embedded toothbrush foreign body in cheek - report of an unusual case.
Sathish R, Suhas S, Gayathri G, Ravikumar G, Chandrashekar L, Omprakash TL.  Eur Arch Paediatr Dent. 2011 Oct;12(5):272-4.
Source: Oral and Maxillofacial Surgery, Sri Siddhartha Dental College, India. [This was suggested by Brian Maurer's comment]

2. Pediatr Dermatol. 2010 Jul-Aug;27(4):410-1.
Cutaneous facial sinus tract of dental origin.Mardones F, Oroz J, Muñoz C, Alfaro C, Soto R.
Dermatology Department, Hospital Clínico, Universidad de Chile, Santiago, Chile.
Abstract: Cutaneous sinus tract on the head and neck area in a child may originate from dental disease. A high degree of clinical suspicion and complementary tests are often needed, as the diagnosis is usually not straight forward. Anatomical correlation is also useful in tracing the affected tooth or teeth. We present the case of a boy with a facial sinus tract that originated from periapical abscesses of maxillary molars.

Saturday, November 17, 2012

The Rudolph Sign

Abstract: 81 year old man with new onset of a red nose

HPI :  This 81 yo man presented with a one day history of a painful inflammatory process of his nose.  He had been in hospital recently and a routine throat culture grew MRSA but since he was asymptomatic, it was not treated. He has atrial fibrillation and meds include warfarin.  Here is the history in his own words.

O/E:  The examination shows an erythematous, slightly indurated area around the bulb of the nose.  

IMPRESSION:  With a history of MRSA and the clinical appearance this looks like nasal vestibular furunculosis as described recently in the dermatologic literature by Dahle andSontheimer.  

Course: He was treated with mupirocin ointment applied intranasally, but after three days there was no change and the process was somewhat worse.  Initially he graded the pain in the nose as a "7" and after three days as a "9" on the Pain Scale of 0 - 10. A culture was taken from the nares and he was placed on minocycline as Bactrim is contraindicated with warfarin.  He was admitted to hospital later that day for uncontrolled atrial fibrillation and  treated with i.v. vancomycin for two days until the preadmission culture came back negative.  Discharged home after two days a papule appeared on the bulb of the nose which drained serosanguinous material and the process started to resolve.  Repeat culture was taken (no pathogens).  When seen at Day 14, he showed marked improvement and he rated his pain as a "O."

Comments:  Nasal vestibular furunculosis (NVF) was described by Dahle and Sontheimer.  They recommended intranasal application of mupirocin with Q-tip applicators.  Our patient did not respond to that which suggests that NVF may need more aggressive therapy in some cases.  We did not perform an initial culture since he'd had one before, but in retrospect we should have done that.  For the clinician, one needs to consider the rare occurrence of cavernous sinus thrombosis with infections of the central face.  The literature on NVF is sparse and most articles lack abstracts.  This area needs more attention as NVF may not be as uncommon as the literature suggests.

Clinical Photos:  
Day i
Day 4

Day 7
Day 14
Day 21

1. Dahle KW, Sontheimer RD. The Rudolph sign of nasal vestibular furunculosis: questions raised by this common but under-recognized nasal mucocutaneous disorder.  Dermatol Online J. 2012 Mar 15;18(3):6.  Free Open Access

2. Laupland KB, Conly JM. Treatment of Staphylococcus aureus colonization and prophylaxis for infection with topical intranasal mupirocin: an evidence-based review.
Clin Infect Dis. 2003 Oct 1;37(7):933-8. Epub 2003 Sep 8.  Email:
Abstract: Most Staphylococcus aureus infections are endogenously acquired, and treatment of nasal carriage is one potential strategy for prevention. We critically appraised the published evidence regarding the efficacy of intranasal mupirocin for eradication of S. aureus nasal carriage and for prophylaxis of infection. Sixteen randomized, controlled trials were appraised; 9 trials assessed eradication of colonization as a primary outcome measure, and 7 assessed the reduction in the rate of infection. Mupirocin was generally highly effective for eradication of nasal carriage in the short term. Prophylactic treatment of patients with intranasal mupirocin in large trials did not lead to a significant reduction in the overall rate of infections. However, subgroup analyses and several small studies revealed lower rates of S. aureus infection among selected populations of patients with nasal carriage treated with mupirocin. Although mupirocin is effective at reducing nasal carriage, routine use of topical intranasal mupirocin for infection prophylaxis is not supported by the currently available evidence. Free Open Access.

3. Dr. Richard Sontheimer sent us this article which may explain why our patient did not respond to mupirocin.  This is a sobering article -- one wonders if resistance patterns elsewhere are as high or whether this was uniqueto the burn center in Tehran.
Burns, 2012 vol. 38(3) pp. 378-82
A high prevalence of mupirocin and macrolide resistance determinant among Staphylococcus aureus strains isolated from burnt patients.
Shahsavan, et. al.  (Tehran University of Medical Sciences)
Abstract: Infections due to Staphylococcus aureus have become increasingly common among burn patients. The antibiotic resistance profile of S. aureus isolates and inducible resistance against clindamycin were investigated in this study. The presence of mecA gene, mupA gene and macrolide resistance genes were detected using PCR and multiplex-PCR. The resistance rate to methicillin, erythromycin and mupirocin were 58.5%, 58% and 40%, respectively. The prevalence of constitutive and inducible resistance among macrolide resistant isolates was 75% and 25%, respectively. Ninety five percent of the isolates were positive for one or more erm genes. The most common genes were ermA (75%), ermC (72%) and ermB (69%), respectively. The ermA gene predominated in the strains with the inducible phenotype, while ermC was more common in the isolates with the constitutive phenotype. The msrA gene was only found in one MRSA isolate with the constitutive phenotype. A total of 27 isolates (25%) carried the mupA gene. All the mupirocin resistant isolates and almost all the erythromycin resistant isolates were also resistant against methicillin which may indicate an outbreak of MRSA isolates with high-level mupirocin and erythromycin resistance in the burn unit assessed.

Thursday, November 08, 2012

Hypopigmented Rings

18 year old college coed with two month history of two incompletely hypopigmented rings on abdomen.  No contacts to area recalled.  On no meds.

O/E:  On right and left abdomen, there are two relatively subtle 5 cm in diameter rings.  No scale.  Possibly a few small incompletely hypopigmented macules on abdomen as well.

Clinical Photo:
Labs:  N/A

Path: Will offer to biopsy

Diagnosis:  Hypopigmented Contact Dermatitis?

Question:  Has anyone seen anything like this?

Chemical leukoderma
Kathryn E O’Reilly MD PhD, Utpal Patel MD PhD, Julie Chu MD, Rishi Patel MD, Brian C Machler MD
Dermatology Online Journal 17 (10): 29  OA Full Text
Department of Dermatology, New York University, New York, New York
Abstract: Chemical leukoderma is defined as an acquired, hypopigmented dermatosis that results from repeated cutaneous application of an agent that destroys epidermal melanocytes in genetically susceptible patients. Chemical leukoderma may develop both at the site of contact with the chemical as well as remotely from the exposure. Avoidance of the causative agent may lead to spontaneous repigmentation, but treatments commonly used in vitiligo, such as narrow-band ultraviolet B phototherapy, PUVA photchemotherapy, or topical immunosuppressants, often are necessary. We present a case of chemical leukoderma secondary to pyrethroid insecticides that has progressed despite avoidance of the agent for over ten years.

Friday, November 02, 2012

Atypical Acneiforn Eruption

Abstract: 18 yo man with two month history of papules and pustules on chin

HPI:  The patient describes mild acne before leaving for college in late August 2012.  He did being a new electric razor with him.  Shortly after arriving at school, he developed an inflammatory process on his chin.  He was treated with Keflex for > one month without relief.

O/E:  Papules + pustules on the chin.  Rest of exam unremarkable.

Photos:  11/2/12

Lab:  Culture grew "Few Serratia marsencens"  plus Staph epidermitis and alpha hemolytic strep

Diagnosis: Gram Negative Acne is favored over Pyoderma faciale

Discussion:  This young man had acne which had been treated with cephalexin for one to two months.  It has not improved and the presentation with pustules suggested gram negative acne.  His college health center's provider wisely performed a bacterial culture which grew Serratia.  Initially, I was thinking of prescribing ciprofloxicillin, but the literature suggests that isotretinoin may be the treatment of choice.

Followup after five months isotretinoin:

1. James WD, Leyden JJ. Treatment of gram-negative folliculitis with isotretinoin: positive clinical and microbiologic response. J Am Acad Dermatol. 1985 Feb;12(2 Pt 1):319-24
Abstract: Thirty-two patients with gram-negative folliculitis were treated with 0.47 to 1.0 mg/kg/day of isotretinoin. Serial microbiologic evaluations demonstrated rapid clearing of the face and nasal mucosa of gram-negative rods. The clinical response was rapid, complete, and induced prolonged remissions. Twenty-six of thirty-two patients developed Staphylococcus aureus nasal carriage by the end of the 20-week treatment course. Isotretinoin has decided advantages over previously reported therapies for gram-negative folliculitis.
Photo from James and Leyden's article, above
2.  Böni R, Nehrhoff B.  Treatment of gram-negative folliculitis in patients with acne.  Am J Clin Dermatol. 2003;4(4):273-6.
Department of Dermatology, University Hospital, Zürich, Switzerland.
Abstract:  Gram-negative folliculitis may be the result of long-term antibacterial treatment in acne patients. It is caused by bacterial interference and replacement of the Gram-positive flora of the facial skin and the mucous membranes of the nose and infestation with Gram-negative bacteria. These Gram-negative bacteria include Escherischia coli, Pseudomonas aeruginosa, Serratia marescens, Klebsiella and Proteus mirabilis. The occurrence of Gram-negative folliculitis should be considered in acne patients in whom oral treatment with tetracyclines has not resulted in a significant improvement of acne lesions after 3-6 months' treatment. The occurrence of Gram-negative folliculitis in acne patients is believed to be generally underestimated, since correct sampling and bacteriology is rarely performed by clinicians. Gram-negative folliculitis in acne and rosacea patients is best treated with isotretinoin (0.5-1 mg/kg daily for 4-5 months).

3.  Massa MC, Su WP.  Pyoderma faciale: a clinical study of twenty-nine patients.  J Am Acad Dermatol. 1982 Jan;6(1):84-91.
Abstract:  Pyoderma faciale is a distinctive entity. Twenty-nine patients with this process were seen in the Mayo Clinic from 1969 to 1980. Twenty-seven patients had follow-up that ranged from 1 month to 11 years, and twenty-two had follow-up of 3 years or more. Clinical features that characterize the patients were (1) female predominance, (2) onset later than teenage acne vulgaris, generally at 19 to 40 years of age, (3) rapid onset and progression, (4) facial involvement with sparing of the back and chest, (5) cysts, swelling, and purulent drainage with a lack of comedones, and (6) paucity of systemic complaints. Patients were treated with multiple forms of therapy simultaneously, often including Vleminckx packs, oral antibiotics, incision and drainage, ultraviolet B, and intralesional steroids. Of twenty-five patients available for follow-up at 1 year, twenty-three had achieved remission, though fifteen patients required ongoing treatment to maintain optimal control. Twenty-three patients had scarring as a sequela. Patients with pyoderma faciale represent a subset of patients with acne in whom the outlook is favorable with appropriate therapy.