Friday, October 09, 2015

Pustular Folliculitis

The patient is a 32 yo man with a 5 year history of an inflammatory process of the mid-upper chest.  He is in good general health and takes no medications by mouth.

The eruption is comprised of discrete papules and pustules.  No areas other than those seen in the photos are involved. Hair growth in the area is unaffected.

Lab:  Culture grew out only Coagulase Negative Staph 1+

Pathology:  The specimens exhibit a dense perifollicular neutrophilic infiltrate forming abscesses and infiltrating follicular epithelium, with admixed lymphocytes, plasma cells, and histiocytes. The histologic differential diagnosis includes both inflammatory and infectious causes of folliculitis. GMS and PAS stains are negative for fungal organisms. Tissue gram stain is negative for bacteria.

Discussion:  This is a healthy young man with a five year history of a localized folliculitis on his chest. If this was fungal, one would expect some hair loss or progression over five years. I found a similar case on PubMed that fit the history, clinical and pathological findings (see below); but still have some questions.  Any suggestions will be appreciated.

Diagnosis: Folliculitis, etiology unclear.  Consider Majocci.

Tinea corporis gladiatorum presenting as a majocchi granuloma.

Kurian A1, Haber RM.  ISRN Dermatol. 2011;2011:767589.  Free FullText.
Abstract: Background. Wrestlers are at increased risk of developing cutaneous infections, including fungal infections caused by dermatophytes. Erythematous lesions due to tinea infections can be mistakenly diagnosed as an inflammatory dermatitis and incorrectly treated with potent topical corticosteroid treatments which cause localized skin immunosuppression. This can eventuate in a Majocchi granuloma which then becomes refractory to topical antifungal therapy. To our knowledge, this is the first case of tinea corporis gladiatorum presenting as a Majocchi granuloma. Observations. A 20-year-old wrestler presented with a 4-year history of a large pruritic, scaly erythematous plaque with follicular papules, and pustules on his right forearm. The lesion had the clinical appearance of a Majocchi granuloma. He had been treated with potent topical corticosteroids and topical antifungal therapy. KOH and fungal culture of the lesion were negative. An erythematous scaly lesion in the scalp was cultured and grew Trichophyton tonsurans. Oral Terbinafine therapy was initiated and complete resolution of both lesions occurred within 6 weeks. Conclusion. The purpose of this report is to inform dermatologists that tinea corporis gladiatorum can present as a Majocchi granuloma and needs to be considered in the differential diagnosis of persistent skin lesions in wrestlers.

Thursday, October 01, 2015

Unusual Vascular Pattern

28 yo man with progressive vascular anomaly of both legs.

History:  The patient is an otherwise healthy 28 years old man with a life-long history of superficial blood vessels of both lower extremities.  This is spreading centripetally. It is painful and has a burning sensation.  No history of edema or ulceration.  No family history.

O/E:  Both lower extremities show prominent superficial arborizing blood vessels.  The red color suggests these are arterioles.  There is no evidence of hemosiderin deposition.

Clinical Images:

Pathology:  A 4 mm punch biopsy was taken.
The specimen exhibits dilated superficial blood vessels surrounded by PAS positive amorphous pink hyaline material. This is consistent with cutaneous collagenous vasculopathy. 
Histopathological Photos taken by  

Hyejin Leah Chung, Dermatopathology Fellow at Boston Medical Center

1. low magnification with dilated superficial blood vessels (H&E, x10)

2. higher magnification with dilated superficial blood vessels surrounded by amorphous pink hyaline material (H&E, x20)

3. PAS stain highlights the amorphous pink material. (PAS, x 20)

Diagnosis:  This does not fit any disorder I have seen. The diagnosis of cutaneous collagenous vasculopathy is interesting.  I think generalized essential telangiectasia needs to be considered as well.

Questions:  Has anyone seen a case?  Any treatment?  Lasers?
1. Cutaneous collagenous vasculopathy with generalized telangiectasia in two female patients.  Perez A, Wain ME, Robson A, Groves RW, Stefanato CM.
Abstract: Cutaneous collagenous vasculopathy is characterized by generalized cutaneous telangiectasia and unique microscopic and ultrastructural vascular changes, consisting of marked collagen deposition within the vascular walls of the post-capillary venules in the superficial dermis. There are only 4 previous cases described in the medical literature, all in males, mostly middle-aged. We have recently seen two female patients with clinical and histopathologic features diagnostic of cutaneous collagenous vasculopathy, indicating that it is not restricted to males. As cutaneous collagenous vasculopathy can be clinically indistinguishable from generalized essential telangiectasia, and histopathologic studies are rarely performed for this condition, it is likely that cutaneous collagenous

2. Generalized essential telangiectasia.
Gordon Spratt EA. Dermatol Online J. 2012 Dec 15;18(12):13.
Abstract: Generalized essential telangiectasia, which is a rare condition that is characterized by the progressive development of telangiectases on the skin, is a clinical diagnosis of exclusion. We present a 65-year-old man with a ten-month history of an asymptomatic eruption of the trunk and proximal aspects of the arms and hands that was comprised of macules and patches of telangiectases. The clinical presentation, associated diseases, hypotheses regarding pathogenesis, differential diagnoses, and reports on treatment modalities are reviewed. The relatively new association of this entity with systemic signs that include hemorrhage as well as the occurrence of generalized essential telangiectasia in patients with a history of hepatitis is discussed.

IMAGES IN CLINICAL MEDICINE. Cutaneous Collagenous Vasculopathy.
Ma DL, Vano-Galvan S. N Engl J Med. 2015 Sep 17;373  Free Full Text.  or DHC.