Presented by Dr. Henry Foong
Ipoh, Malaysia
A 62 yr old man presented with 4 weeks history of pruritic papular lesions on the thighs bilaterally which then spread to the legs. The pruritus was intermittent and he felt feverish at times. No history of trauma. He is a retired fisherman and lives in Teluk Intan about 60 km south of Ipoh, Malaysia.
Ipoh, Malaysia
A 62 yr old man presented with 4 weeks history of pruritic papular lesions on the thighs bilaterally which then spread to the legs. The pruritus was intermittent and he felt feverish at times. No history of trauma. He is a retired fisherman and lives in Teluk Intan about 60 km south of Ipoh, Malaysia.
O/E: showed multiple indurated erythematous papules, non-tender distributed symmetrically over the inner thighs and legs. Superficial erosions and ulcerations were noted on the affected areas. There was no crepitus.
The referring physician suspected elephantiasis. The patient is on oral antibiotics ( metronidazole and unasyn) and albendazole. At one time he was on DEC (diethylcarbamazine) but it was withheld because of side effects.
Lab: Blood counts showed normal TWBC with 7% eosinophils. The physician did a colonoscopy last month and biopsy suggested underlying parasitic colon infection.
Lab: Blood counts showed normal TWBC with 7% eosinophils. The physician did a colonoscopy last month and biopsy suggested underlying parasitic colon infection.
Culture of the skin lesions - Clostridium perfrigens.
A skin biopsy was performed on the skin papules on the thigh.
Pathology: Skin biopsy showed epidermis with marked spongiosis. the dermis show cluster and scattered granulomas with abundant surrounding neutrophils and plasma cells. There is a huge collection neutrophils with necrotic material. There are multinucleate gaints granulomas. The inflammatory cells involved the subcutaneous fat.
Clinical and Pathological Images:
Impression: Sporotrichosis?
Questions: What are your thoughts? What further studies would you consider.
Commnents from Warren Heymann, M.D. "I assume this is an infectious process (not a mimicker, such as Churg-Strauss). I am not aware of clostridium presenting in this manner, but you cannot ignore it. Are you able to obtain imaging to be certain that there is no gas? Could it be a mixed infection - were cultures also performed for anaerobes, fungi, and atypical mycobacteria? You may need help with an ID specialist for this case. Please keep us abreast!"
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