1/48. Cutaneous tuberculosis mimicking cellulitis in an immunosuppressed patient.A 28-year-old lady suffering from systemic lupus erythomatosus (SLE) with diffuse proliferative glomerulonephritis (DPGN) and who was on oral cyclophosphamide and prednisolone presented with left lower limb 'cellulitis'. The 'cellulitis' of the left lower limb failed to respond to usual antibiotics which prompted evaluation of the clinical diagnosis. The diagnosis is made based on the presence of granulomas, multinucleated giant cells and acid fast bacilli on the skin biopsy.- - - - - - - - - - ranking = 1keywords = granuloma (Clic here for more details about this article) |
2/48. mycobacterium avium infection of the skin associated with lichen scrofulosorum: report of three cases.We report three Japanese children with mycobacterium avium infection of the skin who also developed lichen scrofulosorum, a previously undescribed association. They were healthy except for the presence of several noduloulcerative lesions associated with multiple asymptomatic papules on the trunk and extremities. histology of the ulcerative lesions showed features of mixed-cell granuloma, whereas the papular lesions showed features consistent with lichen scrofulosorum. M. avium was identified by polymerase chain reaction-aided dna-dna hybridization analysis in specimens obtained from the noduloulcerative lesions. Both the noduloulcerative and the papular lesions responded well to combination chemotherapy consisting of antituberculous agents and antibiotics.- - - - - - - - - - ranking = 1keywords = granuloma (Clic here for more details about this article) |
3/48. Nodular tuberculid: a report of four patients.The tuberculids are hypersensitivity reactions to mycobacterium tuberculosis (MTB) and include papulonecrotic tuberculid (PNT), lichen scrofulosorum, erythema induratum of Bazin (EIB), and phlebitic tuberculid. Papulonecrotic tuberculid displays papulonecrotic lesions mostly on the extensor surfaces of the limbs. Histopathology shows necrosis, granulomatous inflammation (GI), and occasionally vasculitis, usually in the superficial dermis. erythema induratum of Bazin shows nodulo-ulcerative lesions on the posterior aspect of the legs. Histopathology reveals a septolobular panniculitis, necrosis, GI, and vasculitis. The Mantoux test is strongly positive and associated tuberculosis (TB) may be present in both conditions. MTB cannot be demonstrated with a Ziehl-Neelsen (ZN) stain or cultured. The polymerase chain reaction has demonstrated MTB dna in PNT (50%) and EIB (25%). The tuberculids respond to full anti-TB treatment. We document four patients with nodules on the legs in whom the pathologic changes were situated in the deep dermis and adjacent subcutaneous fat. Nodular tuberculid (NT) is regarded as a suitable term for these lesions. All patients were female. Their ages were 19 months, 12 years, 17 years, and 5 years. All patients presented with nodules on the limbs. These nodules were approximately 1 cm in diameter, dull red or bluish-red, and nontender. Ulceration was not present. The number of nodules varied from a few to many. The Mantoux test was strongly positive in all the patients. Associated pulmonary TB was present in two patients. Histopathology showed GI (n = 4), vasculitis (n = 2), and coagulative necrosis (n = 2). A ZN stain was negative in each case. All patients received anti-TB treatment for 6 months [rifampicin (n = 4), isoniazid (n = 4), pyrazinamide (n = 4), and ethambutol (n = 2)]. At 12 months follow-up, skin and pulmonary lesions had resolved in all. Nodular tuberculid should be distinguished from arthropod bites and papular urticaria, dermal erythema multiforme, evolving vasculitis, evolving folliculitis, and erythema nodosum. Histopathologically NT should be distinguished from other causes of granulomatous vasculitis and GI with or without necrosis. In children with nodules on the limbs unresponsive to routine treatment, skin biopsy should be done to exclude NT. Nodular tuberculid represents a hybrid between PNT and EIB with characteristic clinicopathologic features and should be included in the classification of cutaneous TB.- - - - - - - - - - ranking = 2keywords = granuloma (Clic here for more details about this article) |
4/48. Disseminated BCG infection following bone marrow transplantation for X-linked severe combined immunodeficiency.An 8-month-old boy with X-linked severe combined immunodeficiency (XSCID) developed disseminated bacille Calmette-Guerin (BCG) infection following BCG vaccination at birth. He initially presented with an abscess at the site of BCG vaccination and was begun on three-drug antituberculous treatment (rifampicin, isoniazid, and pyrazinimide). Dissemination was subclinical prior to a human leukocyte antigen (HLA)-identical bone marrow transplant (BMT) from his sister, following which he presented with an acute erythroderma. A skin biopsy specimen revealed granulomas with epithelial histiocytes and giant cells in the reticular dermis, and numerous acid-fast bacilli (AFB) were present on Ziehl-Nielsen stain. A diagnosis of disseminated BCG disease was made. Despite the addition of a fourth antituberculous agent, ethambutol, he did not recover and developed numerous skin abscesses over the following weeks. Examination of pus from these lesions demonstrated numerous AFB. clarithromycin was added as a fifth antituberculous agent. Despite five-drug antituberculous therapy and monthly intravenous immunoglobulin infusions, recurrent abscesses containing AFB developed intermittently until 7 months posttransplant. At follow-up 1 year post-BMT he showed good general physical improvement. All abscesses had healed with scarring, and no further skin lesions had occurred.- - - - - - - - - - ranking = 1keywords = granuloma (Clic here for more details about this article) |
5/48. Cutaneous malakoplakia: a report of two cases with the use of anti-BCG for the detection for micro-organisms.Malakoplakia is an uncommon granulomatous infectious disease that is found primarily in the genito-urinary tract, but may rarely involve the skin. Histologic findings are marked by the presence of foamy macrophages containing basophilic concentric spherules, the Michaelis-Gutman bodies. Micro-organisms are not readily identifiable. Immunostaining with polyclonal anti-mycobacterium bovis (BCG) has been described as a method of identifying bacterial and fungal organisms in situations where organisms may be sparse. We report 2 cases of cutaneous malakoplakia with demonstration of organisms by immunostaining with anti-BCG antibodies.- - - - - - - - - - ranking = 1keywords = granuloma (Clic here for more details about this article) |
6/48. First reported case of mycobacterium ulcerans infection in a patient from china.Buruli ulcers have not been previously described in china, and only once at higher latitudes on the northern hemisphere. A patient who travelled in the Shan Dong Province in the People's Republic of china developed an ulcer which was proven to be a buruli ulcer. The clinical picture and histopathological findings from biopsy specimens are characteristic for a buruli ulcer, and also the growth in culture (Coletsos medium) at a restricted temperature of 30 degrees C. A multiplex polymerase chain reaction (PCR) based on the amplification of the gene encoding for 16S ribosomal rna and a nested PCR based on the mycobacterium ulcerans specific repeated sequence 2404 were performed. These PCR investigations identified the bacteria as M. ulcerans, subspecies shinshuense. The patient was initially treated with clarithromycin and rifampicin, which was changed to ciprofloxacin and rifabutin when rifampicin resistance of the first isolate was established. There were no signs of reactivation of the disease 6 months after the end of treatment. M. ulcerans infection occurs above 30 degrees latitude on the northern hemisphere in china and is caused by M. ulcerans, subspecies shinshuense. This case appears to be cured by chemotherapy alone, in contrast to the general experience that surgical treatment is indicated. The granulomatous reaction with only fragments of acid-fast bacteria in the biopsy at the end of treatment many indicate the development of an adequate cell-mediated immune response leading to resistance to the infection.- - - - - - - - - - ranking = 1keywords = granuloma (Clic here for more details about this article) |
7/48. Lichen scrofulosorum.A 12-month-old boy with pulmonary tuberculosis developed a papular lichenoid eruption which showed epithelioid granulomas on histology, consistent with lichen scrofulosorum. Stains and cultures for mycobacteria in the skin were negative, and a polymerase chain reaction (PCR) analysis failed to detect the dna of mycobacterium tuberculosis in a skin biopsy specimen, thus making lichen scrofulosorum one of the remaining manifestations of M. tuberculosis infection in which evidence of the bacillus has not been found to date. Lichen scrofulosorum is now considered a rare form of tuberculid but should not be neglected.- - - - - - - - - - ranking = 1keywords = granuloma (Clic here for more details about this article) |
8/48. Lichen scrofulosorum - a series of eight cases.Lichen scrofulosorum is a rare entity of children and young adults. The cutaneous lesions are typically symptomless papular eruptions, associated with a strong Mantoux reaction, tuberculosis of lymph nodes and/or other organs. Eight patients between the ages of 5 and 36 years were included in this series. Lesions were commonly seen on the trunk, though a case of involvement of the palms and soles was also observed. Pulmonary tuberculosis was seen in 5 adults; 1 patient each had pleural effusion, tuberculous adenitis and tuberculoma, respectively. Histopathological examination typically showed epithelioid cell granulomas around hair follicles. The histogenesis is unclear, a type IV hypersensitivity reaction provoked by chronic tubercular infection is probable. The patients responded well to antituberculous therapy.- - - - - - - - - - ranking = 1keywords = granuloma (Clic here for more details about this article) |
9/48. Tuberculosis verrucosa cutis associated with tuberculous lymphadenitis.A 34-year-old man presented with a large cutaneous lesion on his left thigh that had started as a small papule when he was 13 years of age. The lesion had enlarged slowly over the last 21 years. The patient had received bacillus Calmette-Guerin (BCG) vaccination in childhood. The family history was significant for tuberculosis. Clinical examination revealed a large, purplish-red, indurated plaque measuring 30 x 29 cm on the left thigh, extending to the buttock area. The edges of the lesion had a serpiginous contour with an involuted center (Fig. 1). A left inguinal lymph node was palpated. Chest X-ray and blood cell count were normal. No other focus of disease was identified. Laboratory testing for human immunodeficiency virus (hiv) infection was negative. Purified protein derivative (PPD) intradermal injection disclosed a 19-mm skin induration. Both the cutaneous lesion and the inguinal lymph node were biopsied. Histopathologic sections of the skin fragment showed epidermal hyperkeratosis, neovascular proliferation, and a dense dermal lymphocytic infiltrate. The histopathology of the lymph node demonstrated few granulomas with focal areas of central necrosis. Staining for fungus was negative. Ziehl-Neelsen staining was negative on both the skin and lymph node specimens. culture for fungus and leishmania sp. was negative. Tissue culture on Lowenstein-Jensen medium from skin and lymph node was positive for Mycobacterium colonies after 5 and 7 weeks, respectively. Multidrug therapy was instituted with rifampin 600 mg/day, isoniazid 400 mg/day, and pyrazinamide 2 g/day for 2 months, and then rifampin 600 mg/day and isoniazid 400 mg/day alone for the next 4 months. An excellent response was obtained at the end of treatment (Fig. 2).- - - - - - - - - - ranking = 1keywords = granuloma (Clic here for more details about this article) |
10/48. Facial granulomatous diseases: a study of four cases tested for the presence of mycobacterium tuberculosis dna using nested polymerase chain reaction.The histopathologic diagnosis of cutaneous tuberculosis (CTB) is often troublesome, because there are several other entities (tuberculids, demodicidosis, granulomatous rosacea, and acne agminata) that may display granulomatous inflammation with caseation necrosis. The current study describes four cases of granulomatous disease of the face. The final diagnosis (assessed on the basis of the clinical response to therapy) was CTB in three cases and granulomatous rosacea in one case. Histologically, epithelioid granulomas were a constant feature; in one case of CTB, they displayed a palisading (granuloma annulare-like) arrangement. Caseation necrosis was a prominent feature only in the case of granulomatous rosacea. Routinely processed biopsy specimens were evaluated with nested polymerase chain reaction (nPCR) for mycobacterium tuberculosis (MBT) dna. The correlation between nPCR results and clinical outcome was less than optimal; in fact, one case showed an excellent clinical response to the antituberculous drug therapy despite the absence of MBT dna amplification. In granulomatous diseases of the face, the importance of evaluating not only nPCR but the overall clinicopathologic picture so as to avoid diagnostic misinterpretations is emphasized.- - - - - - - - - - ranking = 12keywords = granuloma (Clic here for more details about this article) |
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