P6007
Erysipelas-like cutaneous leishmaniasis in a white man
Tee Wei Siah, MBChB, University Hospital of North Durham, Durham, United
Kingdom; Fraser Charlton, Royal Victoria Infirmary, Newcastle Upon Tyne,
United Kingdom; Shyamal Wahie, University Hospital of North Durham, Durham,
United Kingdom; Thomas Lavender, Royal Victoria Infirmary, Newcastle Upon
Tyne, United Kingdom; Uli Schwab, Newcastle University Medical School,
Newcastle Upon Tyne, United Kingdom
Cutaneous leishmaniasis (CL) is caused by intracellular protozoa of the genus
Leishmania, transmitted by infected female sandflies. The incidence of CL is
estimated to be 1.5 million new cases per year. CL has many different presentations,
but the classical course of this disease is the appearance of small papules which
progress to ulcerated plaques or nodules on exposed sites. We report a patient who
demonstrated a rare and unusual presentation of CL mimicking periorbital cellulitis.
A 61-year-old white man presented with a 3-month history of a slowly enlarging
lesion on the right temple. It had become progressively painful and spread to involve
the right eyelid. He had previously been on holiday in Ibiza 5 weeks before the onset
of the problem. Clinical examination revealed an erythematous, edematous plaque
with central crust and superficial ulceration on the right temple and prominent
periorbital oedema affecting the right eye resembling erysipelas. He did not respond
to treatment with flucloxacillin and topical steroid. Incisional biopsy from the lesion
demonstrated a dense dermal mixed inflammatory cell infiltrate. In addition, there
were numerous small round to oval basophilic organisms weakly stained with
Giemsa stain found in histiocytes. Leishmania Donovani complex DNA was detected
on skin biopsy PCR. Laboratory findings showed pancytopenia and abdominal
ultrasound was normal. Subsequent bone marrow trephine could find no evidence
of leishmaniasis. Blood leishmania IFAT and PCR were negative. The patient was
diagnosed with CL and commenced on intravenous sodium stibogluconate (20
mg/kg) for 20 days. Treatment was complicated by a collapse caused by a prolonged
QT interval secondary to hypokalemia (2.3 mmol/L) induced by sodium stiboglu-
conate. He has since completed treatment and has residual mild periorbital edema.
The erysipelas presentation of CL is rarely reported. The reason for this uncommon
presentation is unclear though factor including an abhorrent host immune response
has been postulated. This case highlights an unusual presentation of CL in a
nonendemic country and the importance of taking a travel history in order to raise
suspicion of this rare diagnosis in immunocompetent patients, as well as the
potential complications of treatment. The associated pancytopenia with no
evidence of bone marrow or visceral involvement is suggestive of an immune-
mediated epiphenomenon.
Commercial support: None identified.
P6177
Erythema induratum of Bazin secondary to tuberculin skin test
Celia Posada, MD, Dermatology Service, Complexo Hospitalario de Pontevedra,
Pontevedra, Spain; Alberto Pena, Tuberculosis Unit, Internal Medicine
Department, Pontevedra, Spain; Carlos De La Torre, Dermatology Service,
Complexo Hospitalario de Pontevedra, Pontevedra, Spain; Luis Anibarro,
Tuberculosis Unit, Internal Medicine Department, Pontevedra, Spain; Nuria
No, Dermatology Service, Complexo Hospitalario de Pontevedra, Pontevedra,
Spain; Rosa Mar
a Pardavila, Pathology Service, Pontevedra, Spain
The causal relationship between erythema induratum of Bazin (EIB) and tubercu-
losis (TB) remains controversial because mycobacteria cannot be cultured from skin
lesions. This association has been traditionally based on circumstantial pieces of
evidence. During the last years, the variable percentage of identification of the
organism DNA by PCR of biopsy lesions has reactivated this discussion. We report a
50-year-old man with a 15-year history of recurrent painful nodules on his legs and
abdomen with central ulceration. He recognized previous contact with TBC.
Complementary tests, included cutaneous biopsy, confirmed the diagnosis of EIB.
Tuberculin skin test was strongly positive with vesiculation (28 mm). One month
later, the patient developed painful nodular lesions surrounding tuberculin skin test
area. Biopsy of these new lesions showed similar findings of that taken from the legs.
Antituberculous chemotherapy was given during 6 months without adverse effects
and resolution of cutaneous lesions. Althought the pathogenesis of EIB is not
completely understood, most authors consider it to be a reactive disorder related to
several etiologic factors, one of which may be TB. In these cases, EIB belongs to
tuberculids, a group of disorders resulting from a hypersensitivity reaction to an
extracutaneous source of Mycobacterium tuberculosis. Authors suggest that EIB is
caused by a T-cell mediated immune response. EIB has already been reported once
after BCG vaccination in an infant but, to the best of our knowledge, this is the first
report of EIB after tuberculin skin test. This finding supports the current idea of EIB
as an immunity phenomenon secondary to, in this case, M tuberculosis antigen.
Commercial support: None identified.
AB118 J AM ACAD DERMATOL
P6303
Evaluation of 166 leprosy patients under 15 years of age in a public
hospital, Rio de Janeiro/Brazil
Gabriel Monteiro de Castro Chaves, MD, Institudo de Dermatologia Rubem David
Azulay, Rio de Janeiro, Brazil; Francisco Reis Vianna, MD, Institudo de
Dermatologia Rubem David Azulay, Rio de Janeiro, Brazil; Joao Carlos Regazzi
Avelleira, MD, PhD, Institudo de Dermatologia Rubem David Azulay, Rio de
Janeiro, Brazil; Omar Lupi da Rosa, MD, PhD, UNIRIO, Rio de Janeiro, Brazil
Background: Brazil has a great importance on the world stage of leprosy, and in
2009, the second highest incidence (37,610), second only to India (133,717), the
year that 244,796 new cases were detected according to the WHO.
Methods: An observational retrospective analysis of 166 patients, aged under 15, at Rio
de Janeiro, diagnosed with leprosy and who underwent clinicoepidemiologic analysis,
smear and histopathology, in the period 1990-2010. In this study we analyzed data such
as gender, age, clinical form, operational classification, degree of initial disability, the
initial smear, presence of reaction, the site of injury and initial signs and symptoms.
Results: Sex: F: 50.6% (n 84), M: 49.4% (n 82) AGE: 3-14 years, 63% (n 105)
adolescents and 37% (n 61) of children. Clinical form: T (49%-81), B (24.6%-41), I
(13%-22) and L (13%-22). Operational classification: PB: 63.9% (n 106), MB: 36.1%
(n 60) Disability 0 (84.3%, n 140) Grade 1 (6%, n 10) Grade 2 (6.6%, n 11)
Disability x Form B - 29.2% I - 0% T - 4.9% L - 22.7% Smear: Negative 46.3% (n 77)
Positive: 31.3% (n 52) Reaction Type 1- 9% (n 15) Type 1 + neuritis 0.6% (n 1)
Type 2 - 3% (n 5) Type 2 + neuritis - 1.8% (n 3) Early signs and symptoms
Hypochromic - 77.1% (n 128) Erythematous plaque - 9% (n 15), Paresthesia -
6.6% (n 11) Site of injury Face - 28.9% (n 48) Limbs - 49.3% (n 82) Trunk -
10.8% (n 18) Disseminated - 5.4% (n 9).
Discussion: Differences do not occur in children in relation to sex, since it often is
indoor exposure. Most patients were adolescents, explained by the long incubation
period. Among children, we see an early exposure to the bacillus in these households,
indicating the high endemy in Brazil, increased chain of transmission of the bacillus in
the community, and a deficiency in surveillance and disease control. The lack of early
diagnosis leads to the evolution of indeterminate forms. The predominance of
paucibacillary forms is found in the literature for children as expected. The incidence
of leprosy reactions (16%) show the need of service be prepared for the management
of these events potentially associated with disability. The high percentage of patients
with disability at diagnosis, may reflect late diagnosis and also theoccult prevalence of
the disease. Borderline and lepromatous were observed with the highestincidence of
disabilities, in accordance with the literature. The predilection of lesions for exposed
areas has been verified for many years, regardless of mode or route of transmission.
Commercial support: None identified.
P6824
Generalized granuloma annulare in patients with syphilis
Fred Bernardes Filho, MD, Instituto de Dermatologia Prof. Rubem David Azulay da
Santa Casa da Miseric
ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil;
Andreia Oliveira Alves, Universidade Metropolitana de Santos (UNIMES), Santos,
Brazil; Camila Bussad, Instituto de Dermatologia Prof. Rubem David Azulay da Santa
Casa da Miseric
ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil;
Mariana Raz
e, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da
Miseric
ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Patr
cia
Almeida, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da
Miseric
ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Stephanie
Bianco, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da
Miseric
ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Yana Dias
Almeidinha, Universidade de Ribeir~ao Preto (UNAERP), Ribeir~ao Preto, Brazil
Background: Granuloma annulare can manifest itself in several clinical forms just as
localized, generalized, subcutaneous, and perforating one, and each one present its
owns peculiarities. The diagnosis relies on clinical features, however, the biopsy
may be recommended in cases where lesions are uncommon. Syphilis is a disease
which has periods of activity and remission, systemic involvement, and progression
to severe complications, when treatment is not started or is improperly done. The
mucocutaneous features can mimic many diseases, and atypical forms can make
diagnosis a challenge. Syphilis can show a large variety of lesion polymorphism
which often complicates its differential diagnosis.
Case report: A 50-year-old man was guided to dermatologic examination because he
has been presenting some lesions in his trunk and upper limbs for about 3 years. He
noted that for approximately 4 months, he had a wound on the penis, but, as it was
asymptomatic and disappeared spontaneously, he did not look for medical treat-
ment. During dermatologic examination, he showed over 15 erythematous papular
lesions, some of them with ring conformation and others circulates, distributed all
over the trunk and upper limbs. Exams: VDRL titration with 1/4, FTA-ABS IgG
reagent, TPHA: reagent, serology for HIV was negative, skin biopsy, conclusion:
granuloma annulare. Combining clinical features to the exams and biopsy results,
we diagnosed generalized granuloma annulare and syphilis. Corticosteroids were
prescribed for occlusive lesions located in the trunk and upper limbs and benzene
penicillin 7.2 million UI total dose divided into three doses at a 7-day interval.
Discussion: Granuloma annulare lesions can simulate tertiary syphilitic lesions. In
this case, we concluded that the cutaneous lesions were granuloma annulare
because of its clinical characteristics and confirmation with histopathology. Another
important point was the occurrence of regression of the biopsied lesions, a common
phenomenon that usually happens in granuloma annulare cases, a phenomenon
known as reverse Koebner or Renbok. However, as the patient had specific serology
for syphilis, it was necessary to medicate the patient with benzene penicillin dose
protocol as recommended by the Ministry of Health. The case reported is of utmost
importance because it was described 2 distinct dermathologic diseases that
apparently can show the same semiology.
Commercial support: None identified.
APRIL 2013