Pyoderma vegetans

BACKGROUND

Pyoderma vegetans is a rare condition that is clinically characterized by large verrucous plaques with elevated borders and multiple pustules. The etiology of this disorder remains unknown.

OBJECTIVES

We describe a 24-year-old woman with rapidly evolving pyoderma vegetans. Our patient had the unique additional findings of a highly elevated serum IgE level and a history of hidradenitis suppurativa.

CONCLUSIONS

Pyoderma vegetans is diagnosed on clinical and histological criteria. Differentiation must be made from disorders such as pyoderma gangrenosum, Sweet's syndrome, and deep fungal infections. We illustrate a case of pyoderma vegetans and review the literature on this rare disorder. Clinical and histological criteria for diagnosis are presented, as well as differentiation from some mimicking disorders.

Pyodermatitis-pyostomatitis vegetans: a clinical course of two decades with response to cyclosporine and low-dose prednisolone

Pyodermatitis-pyostomatitis vegetans is a rare, polymorphous inflammatory disorder of the skin and oral mucosa first described by Hallopeau in 1898. On the skin papules, pustules and reddish brown annular vegetating plaques develop, most frequently in the intertriginous areas. In the mouth, yellowish flat ulcerations arise, typically in the shape of "snail tracks". The association with inflammatory bowel disease is very common. An unusual case with a chronic relapsing course of 2 decades is presented. Gastrointestinal inflammation was absent. Prednisolone in high and medium doses suppressed most lesions. Various attempts with other drugs (dapsone, isotretinoin, azathioprine) to reduce the corticosteroid dose failed. This is the first report of the successful treatment of pyodermatitis-pyostomatitis vegetans with cyclosporin A, which proved to be highly effective in this regard. The unknown aetiopathology of pyodermatitis-pyostomatitis vegetans is discussed.

Extraintestinal Crohn's disease: case report and review of the literature

Crohn's disease is a granulomatous inflammatory bowel disease. Its pathologic findings include noncontiguous chronic inflammation and noncaseating granulomas. Any segment of the gastrointestinal tract can be involved, but it is uncommon to find that Crohn's disease has spread beyond the intestine. We describe the case of a man with extraintestinal Crohn's disease that was marked by quiescent involvement of the lower gastrointestinal tract and florid involvement of the nasal cavity, supraglottic structures, glottis, and skin.

An outbreak of pyodermas among neonates caused by ultrasound gel contaminated with methicillin-susceptible Staphylococcus aureus

OBJECTIVE

To investigate an outbreak of methicillin-susceptible Staphylococcus aureus (MSSA) infections in a neonatal clinic.

DESIGN

Prospective chart review, environmental sampling, and genotyping by two independent methods: pulsed-field gel electrophoresis (PFGE) and randomly amplified polymorphic DNA polymerase chain reaction (RAPD-PCR). A case-control study was performed with 31 controls from the same clinic.

SETTING

A German 1,350-bed tertiary-care teaching university hospital.

RESULTS

There was a significant increase in the incidence of pyodermas with MSSA; 10 neonates in good physical condition with no infection immediately after birth developed pyodermas. A shared spatula and ultrasound gel were the only identified infection sources. The gel contained MSSA and was used for hip joint sonographies in all neonates. PFGE and RAPD-PCR patterns from 6 neonates and from the gel were indistinguishable and thus genetically related clones. The case-control study revealed no significant risk factor with the exception of cesarean section (P=.006). The attack rate by days of hip-joint sonography between April 15 and April 27, 1994, was 11.8% to 40%.

CONCLUSIONS

Inappropriate hygienic measures in connection with lubricants during routine ultrasound scanning may lead to nosocomial S. aureus infections of the skin. To our knowledge this source of S. aureus infections has not previously been described.

Lupus erythematosus vegetans

A 29-year-old woman with known systemic lupus erythematosus presented with exudative and vegetative plaques bilaterally on her groins. The clinical and histological findings indicated a diagnosis of pyodermatitis vegetans. Direct immunofluorescence studies revealed the presence of a definite basement membrane zone band for IgG, IgM and C3, favouring lupus erythematosus. We propose the term lupus erythematosus vegetans for this combination of clinicopathological and immunohistological findings.

Hypercalcemia associated with granulomatous disease in a cat

A 6-year-old cat was examined because of recurrence of a draining mass involving skin and subcutaneous tissues of the caudoventral aspect of the abdomen. Previous treatment included administration of antimicrobial drugs and corticosteroids and surgical excision. Atypical mycobacteria were seen during cytologic examination of biopsy specimens of the mass; Nocardia sp was cultured. While hospitalized, the cat developed hypercalcemia and was found to have high serum calcitriol concentrations. Treatment consisted of administration of ciprofloxacin and trimethoprim-sulfadiazine because of the infection and administration of sodium chloride solution, furosemide, and calcitonin because of the hypercalcemia. The cat recovered.

Leishmaniosis and generalized demodicosis in three dogs: a clinicopathological and immunohistochemical study

This paper describes the clinicopathological and immunohistochemical aspects of the skin lesions in three dogs with leishmaniosis and generalized demodicosis. Diffuse alopecia, crusts, folliculitis and furunculosis, as commonly seen in generalized demodicosis, were prominent in all the dogs. MicroIscopically, there was a diffuse and perifollicular superficial and deep granulomatous dermatitis and, in two dogs, both Copyright Demodex canis mites and Leishmania spp. amastigotes were observed in the same lesions. Numerous Mac387(+)macrophages were observed in the inflammatory infiltrates, but macrophages loaded with amastigotes were Mac387(-). In all cases, immunoreactive CD3 lymphocytes were sparse, both in the granulomatous and perifollicular infiltrates. There were numerous IgG+, IgG4(+)-secreting plasma cells in areas of folliculitis and furunculosis and fewer IgG2(+), IgG3(+), IgA+and IgM+-secreting plasma cells in the inflammatory infiltrate. In all cases, MHC Class II was expressed by the majority of dermal macrophages and dendritic cells, as well as by lymphocytes and fibroblasts. The paucity of CD3(+)lymphocytes, usually abundant in D. canis lesions, points to leishmania-induced cell-mediated immunosuppression as a predisposing factor for generalized demodicosis.

Composition of protein in urine from dogs with pyoderma

The protein fractions in urine from proteinuric dogs with and without pyoderma were estimated. Fifteen dogs with pyoderma (five with superficial and 10 with deep pyoderma) were compared with 10 dogs with glomerulopathy and 27 dogs with diseases other than pyoderma or urinary tract problems. Agarose gel electrophoresis was used to fractionate the proteins. Three types of electrophoretogram were obtained with albuminuria, globulinuria and serum-like profiles. An albuminuria profile was found in eight of the 27 dogs with other diseases, in three of the five dogs with superficial pyoderma, in eight of the 10 dogs with deep pyoderma and in all 10 dogs with glomerulopathy. The albuminuria profile (mean [sem] albumin/globulin ratio 1.98 [0.10]) was also characterised by alpha 1b, alpha 2a and beta 2 globulin peaks in all 29 dogs with this profile, which was therefore thought to indicate that albuminuria (glomerular proteinuria) was a result of glomerular damage and inflammation because alpha 1b, alpha 2a, and beta 2 globulins are considered to be acute phase proteins. The serum-like profile (mean [sem] albumin/globulin ratio 0.72 [0.01]) was observed in 13 per cent of the proteinuric dogs examined and contained all the protein fractions normally detected by electrophoresis of serum. The profile was considered to be a variant from of the albuminuria profile, probably indicating advanced glomerular lesions and inflammation. The globulinuria profile (mean [sem] albumin/globulin ratio 0.33 [0.08]) was significantly different from the other two in that it was characterised by a low albumin peak and the presence of globulin fractions not clearly distinguishable from each other because of their confluency and absence of individual peaks. This profile could indicate severe glomerulotubular lesions and degradation of certain protein fractions. It could also be a result of increased secretion of tissue and other proteins by damaged tubules. It was concluded that glomerular damage leads to glomerular proteinuria characterised by high proportions of albumin together with alpha 1b, alpha 2a and beta 2 globulins in lower but significantly diagnostic proportions.

[Pyostomatitis-pyodermatitis vegetans uncovering a case of Crohn disease]

BACKGROUND

Pyostomatitis-pyodermatitis vegetans is an uncommon condition associated with chronic inflammatory bowel disease in 75% of the cases, usually hemorrhagic rectocolitis.

CASE REPORT

A 48-year-old man was referred for recent development of pustulous lesions of the lips and buccal mucosa and weight loss. He complained of abdominal pain and intermittent diarrhea which had persisted for more than one year. During the last three months, a pseudotumoral plaque with a pustulous rim had developed over the two distal phalanxes of the right middle finger in association with ungueal lysis and nodular, vegetating and crusted lesions on the lateral aspect of the left arm. Small pustules covered the entire buccal mucosa excepting the tongue and the glans forming a typical snail trace aspect. Bacterial and mycological samples were negative. The histology reports for skin and mucosa were similar: epithelial hyperplasia, intra- and subepithelial granulocyte micro-abscesses and polymorphous infiltration of the superficial derma with numerous neutrophils and eosinophils. There was a discrete interkeratinocytic fluorescence at direct immunofluorescence but indirect immunofluorescence was negative. Anti-desmogleine 1 immunolabeling showed typical normal skin uptake and immunotransfer was negative. Digestive tract endoscopy and histopathology examination of the bowel specimens confirmed the diagnosis of Crohn's disease. Clinical manifestations improved dramatically with prednisone.

DISCUSSION

This case of pyostomatitis-pyodermatitis vegetans involved several aspects rarely reported in the literature: a) the cutaneomucosal signs were inaugural; b) the association with Crohn's disease; c) the presence of lesions to the genital mucosa; d) the unusual localization of the inaugural skin manifestations. This clinical entity has now been clearly distinguished from pemphigus vegetans. There was however a long debate on the similar clinical, histological and even immunological expressions. We suggest that pyostomatitis-pyodermatitis vegetans belongs to the spectrum of neutrophilic dermatoses and other authors even propose it is a clinical form of pyoderma gangrenosum.

Pyodermia chronica glutealis complicated by acromegalic gigantism

We report a case of pyodermia chronica glutealis complicated by acromegalic gigantism associated with hyperprolactinemia. The serum prolactin, growth hormone, adrenocorticotropic hormone, and 11-deoxycortisol levels were elevated, but the estradiol and dehydroepiandrosterone-sulphate levels were within normal limits. However, the testosterone level was very low. Histopathologically, we found sinus tracts and scarring in a specimen from the buttocks. We could not immunohistochemically detect clear androgen, growth hormone, or prolactin receptors at any site. The patient was a man with a height of 197 cm and weight of 140 kg, he had clinical features of active acromegaly such as excessive sweating and increased thickness of soft tissue. He was also diagnosed with diabetes mellitus. Under such conditions, bacteria could easily grow and lesions might have been aggravated by the heavy pressure from his weight, a possible causes of his pyodermia chronica glutealis.

Pyodermatitis-pyostomatitis vegetans

A 43-year-old woman developed annular and pustular cutaneous lesions preceded by tiny yellow pustules coating the surface of the oral mucosa. The clinical, histological and immunopathological evidence clearly showed that the patient had pyodermatitis-pyostomatitis vegetans. It is suggested that this disease is a distinct entity which should be differentiated from pemphigus vegetans.

Leukocyte mobilization to skin lesions, determination of cell surface receptors (CD11b/CD18) and phagocytic capacities of neutrophils in dogs with chronic deep pyoderma

A suction blister technique was used in eight dogs with chronic deep pyoderma to determine chemotaxis in vivo. By flow cytometry the expression of adhesion molecules (CD11b/CD18) on exudative and peripheral neutrophils were analyzed in 11 healthy dogs and six dogs with chronic deep pyoderma. Phagocytosis in vitro capacities of exudative and peripheral neutrophils were analyzed in six healthy dogs and six dogs with chronic deep pyoderma. Dogs with chronic pyoderma showed significantly better chemotaxis in vivo compared with the healthy dogs (P < 0.05). Expression of adhesion molecules CD11b and CD18, and phagocytosis was significantly (P < 0.05) better in the dogs with pyoderma compared with the healthy dogs. In both groups exudative cells expressed significantly (P < 0.05) more CD11b/CD18 receptors compared with blood neutrophils. We conclude that there are no serious functional disturbances detectable in the peripheral neutrophils, nor in the exudative neutrophils from dogs with chronic deep pyoderma.

Papular urticaria: a histopathologic study of 30 patients

Papular urticaria is the result of hypersensitivity (id-reaction) to bites from certain insects such as mosquitoes gnats, fleas, mites, and bedbugs. Papular urticaria is common in childhood and is characterized by symmetrically distributed pruritic papules and papulovesicles. Scratching causes erosions and ulcerations. Pyoderma is common. Lesions occur in crops. The histopathologic features of papular urticaria are inadequately documented. In a prospective study we recorded the histopathologic features of 30 patients (female, 18; male, 12) with papular urticaria. Their ages ranged from 6-343 months (median = 21 months, mean = 37.73 months). Features that presented in more than 50% of cases included mild acanthosis, mild spongiosis, exocytosis of lymphocytes, mild subepidermal edema, extravasation of erythrocytes, a superficial and deep mixed inflammatory cell infiltrate of moderate density, and interstitial eosinophils. We recognized lymphocytic (n = 4), eosinophilic (n = 9), neutrophilic (n = 7), and mixed (n = 9) subtypes. Immunohistochemistry was performed on formalin-fixed, paraffin-embedded sections from 10 cases and revealed abundant T-lymphocytes (CD45RO, CD3) and macrophages (CD68) in all cases. B-lymphocytes (CD20) and dendritic antigen-presenting cells (S100) were absent. Direct immunofluorescence staining was conducted on cryostat-prepared sections from 26 specimens. Deposition of IgA, IgG, IgM, C3, and fibrin could not be demonstrated. The histopathologic differential diagnosis of papular urticaria includes other spongiotic dermatitides, pityriasis lichenoides et varioliformis acuta, the pruritic papular eruption of human immunodeficiency virus disease, and papulonecrotic tuberculid. Papular urticaria with marked spongiosis and a dense inflammatory cell infiltrate cannot be reliably distinguished from arthropod bites on clinical and histopathologic grounds. The present study provides morphologic and immunohistochemical evidence that a type I hypersensitivity reaction plays a central role in the pathogenesis of papular urticaria. The putative antigen remains undetermined.

Monoclonal gammopathy in a dog with chronic pyoderma

A monoclonal gammopathy composed of immunoglobulin G, with concurrent light-chain proteinuria and generalized lymph node plasmacytosis, was associated with chronic pyoderma in a dog. A uniform population of plasma cells was observed cytologically and histologically in multiple lymph node specimens. A diagnosis of monoclonal gammopathy of unknown significance was eventually made by exclusion of other known causes of monoclonal gammopathy, resolution after antibiotic therapy, and no evidence of lymphoproliferative disease after 11 months of follow-up and subsequent necropsy. This report expands the diagnostic considerations for monoclonal gammopathies in the dog.

Pyoderma fistulans sinifica (fox den disease): a distinctive soft-tissue infection

Pyoderma fistulans sinifica (PFS, also referred to as fox den disease because its multiple fistulae and sinuses resemble the structure of a fox den) is a distinct chronic infectious disease in which epithelialized tracts form within the subdermal fatty tissue. PFS, which has not been previously described in the English-language literature, must be differentiated from hidradenitis suppurativa, pilonidal sinus, and perianal fistula. The fistulous tracts of PFS are always lined by stratified squamous-cell epithelium but, unlike those of hidradenitis, reach deep into the subcutaneous fat, run epifascially for long distances, and have no relation to skin appendices. We report on 10 men (mean age +/- SD, 36 +/- 5 years) with PFS (mean duration +/- SD, 11 +/- 7 years). Bacterial cultures of affected tissue from these patients yielded a total of 14 facultative and 31 obligate anaerobic species. Treatment consisted of wide en-bloc excision down to the fascia, including all fistulae. Antibiotic therapy temporarily reduced purulent discharge but did not eradicate the infection. Two patients who underwent fistulotomy without wide en-bloc excision developed recurrences.

Tissue immunoglobulin G subclasses observed in immune-mediated dermatopathy, deep pyoderma and hypersensitivity dermatitis in dogs

A panel of monoclonal antibodies has been used to define three of the four subclasses of canine immunoglobulin G (IgG2, IgG3 and IgG4) in formalin-fixed tissues. These reagents, together with a polyclonal antiserum specific for the Fc region of canine IgG, were used in an immunohistochemical study of biopsies of skin from five normal dogs and from the lesions of canine pemphigus foliaceus in seven dogs, discoid lupus erythematosus in eight dogs, bullous pemphigoid in one dog, cutaneous drug eruption in two dogs, deep pyoderma in 13 dogs and hypersensitivity dermatitis in eight dogs. IgG autoantibody was identified in the skin of all the dogs with immune-mediated dermatoses by using the polyclonal reagent, and antibody of the IgG2 and/or IgG4 subclass was identified in the epidermis of three of the dogs with pemphigus foliaceus, two of those with discoid lupus erythematosus and in the dog with bullous pemphigoid. In all the lesions, the infiltrate of dermal plasma cells consisted of similar numbers of IgG2 and IgG4 bearing cells, with relatively few IgG3 positive cells. The total number of these cells was generally approximately the same as or greater than the number of cells labelled with the polyclonal reagent. There was no significant difference between the IgG-bearing plasma cell infiltrate in German shepherd dogs with deep pyoderma and that in dogs of other breeds. The infiltration of IgG2 and IgG4 bearing plasma cells into the skin of dogs with a range of cutaneous disorders was related to the selectively enhanced serum levels of these subclasses in the diseased dogs.

[Pyoderma gangrenosum vegetans. An overview of chronic pyoderma vegetans and pyoderma gangrenosum]

A case simulating extraordinarily extensive chronic vegetating pyoderma revealed itself in its course to be pyoderma gangrenosum. The bacterial flora varied due to a secondary colonization; there was no response to antibiotics but there was to corticosteroid, azathioprine and clofazimine therapy. IgA-paraproteinemia was found. Pyoderma gangrenosum has historically been considered to be a chronic ulcerous pyoderma and is not a disease of bacterial origin. Reviewing the literature available since the turn of this century, chronic vegetating pyoderma is compared with the latter from the viewpoint of clinical features, histopathology, immunology, course and treatment. There are so many convincing parallels between the two conditions that we would like to propose that we stop regarding them as distinct entities and instead view them as parts of a spectrum of the same immunopathological process.