Blastomycosis-like Pyoderma with Good Response to Acitretin

Athena: Specialty Certificate Examination case for infectious disease

A 63-year-old man presented with an extensive pruritic and painful rash on his arm that had gradually progressed over 8 years after pricking his wrist on a bush, despite treatment with antifungals and antibiotics. Physical examination showed numerous erythematous, coalescing verrucous plaques in a sporotrichoid distribution on the arm with crust and scale. We discuss further tests, diagnosis and treatment.

Case Report: Disseminated Vegetating Plaques Occurring over Chronic Recalcitrant Dermatophytosis in an Immunocompromised Patient

Blastomycosis-like pyoderma (BLP) is an uncommon tissue response possibly to bacterial infection that presents as vegetative skin lesions usually in immunocompromised patients. Staphylococcus aureus is the most frequent pathogen implicated in BLP. Here, we report the case of a 32-year-old man who had ulcerative vegetating lesions on extremities for 3 months over preexisting recalcitrant tinea lesions. The patient was hypertensive with a history of chronic graft rejection after renal transplantation 8 months earlier and was on long-term immunosuppressants. Investigations revealed anemia, mild hyperglycemia, and elevated serum creatinine. Histopathology showed suppurative and fibrosing perifolliculitis with moderate pseudocarcinomatous hyperplasia and the culture of biopsy specimen demonstrated growth of Escherichia coli and Citrobacter koseri. The diagnosis of BLP overlying dermatophytoses was made. The skin lesions improved completely with parenteral antibiotics. Local immune dysregulation by dermatophytoses along with iatrogenic immunosuppression may have favored this rare pyoderma.

Blastomycosis-like pyoderma: a pitfall for the misdiagnosis of squamous cell carcinoma

Blastomycosis-like pyoderma is a rare cutaneous disease presenting as solitary or multiple verrucous or ulcerated plaques and nodules in a susceptible patient. The diagnostic criteria include characteristic verrucous plaques with pustules and elevated borders, histopathologic findings of pseudoepitheliomatous hyperplasia with abscesses, growth of at least one bacterium in tissue culture, and exclusion of other infectious sources. This report describes a case of a 62-year-old man with poorly controlled type 2 diabetes mellitus who presented with plaques, nodules, and ulcers in the bilateral inguinal area and right ankle. The patient was initially misdiagnosed with multiple squamous cell carcinomas and underwent several surgeries. A review of the pathology slides revealed pseudoepitheliomatous hyperplasia with multiple dermal abscesses, while repeated wound and tissue cultures were positive for coagulase-negative Staphylococcus. Blastomycosis-like pyoderma was diagnosed. The patient was subsequently treated with culture-guided prolonged antibiotic therapy followed by intralesional steroid injection, which led to gradual resolution of the lesions. This article is protected by copyright. All rights reserved.

Retinoid combined with photodynamic therapy against hyperkeratotic chromoblastomycosis: A case report and literature review

Chromoblastomycosis (CBM) is a chronic granulomatous fungal infection caused by melanised or brown-pigmented fungi. It can lead to chronic persistent infections and may cause incapacity for labour in some severe clinical forms. The optimal therapy for CBM is still uncertain. Here, we reported the case of a 66-year-old male who has had red plaque and recurrent keratinised protrusions on his right forearm for 20 years. He was treated orally with terbinafine, itraconazole and isotretinoin. He also received carbon dioxide(CO₂ ) laser to eradicate the keratinised protrusions and promote the penetration of photosensitiser. After the CO₂ laser, 5-aminolevulinic acid-based photodynamic therapy (ALA-PDT) was adopted immediately to inhibiting the growth of fungi in subcutaneous tissue. The patient received an important improvement with a plaque and crust reduction after 4 months. For such recalcitrant case of chromoblastomycosis, the use of retinoid, CO₂ laser combined with ALA-PDT may be a new adjuvant therapy. We further reviewed the cases of chromoblastomycosis treated with laser, photodynamic therapy or retinoic acid.

Case Report: Successful Treatment of Chromoblastomycosis Caused by Fonsecaea monophora in a Patient with Psoriasis Using Itraconazole and Acitretin

Chromoblastomycosis is a worldwide chronic subcutaneous infection caused by dematiaceous fungi and clinically characterized by verrucous lesions. Herein, we report a rare case of chromoblastomycosis caused by Fonsecaea monophora in a 60-year-old male carpenter with a 40-year history of psoriasis from Shandong in northern China. A fungal infection coexisting with psoriasis presents a management dilemma. Our patient responded well to combined itraconazole and acitretin therapy and the lesions resolved completely after 1 month of treatment.

Blastomycosis-Like Pyoderma- A Rare Case Report

Blastomycosis-like pyoderma is a rare, cutaneous bacterial infection of skin, seen in malnourished individuals, in a poor state of health and manifests as vegetating skin lesions. It is an unusual tissue reaction possibly to bacterial infection, the most common organism being Staphylococcus aureus. This case report is of a 35-year-old male who presented with thick verrucous surfaced plaques and papules on trunk and extremities since 2 months. Investigations revealed anaemia with hypochromasia, neutrophilic leucocytosis, hypo-proteinemia and hypo-albuminemia with reversal of A/G ratio. Pathergy test was negative. Pus on Gram's stain showed plenty of pus cells, and negative for AFB and fungal stain. On culture of pus grew Coagulase negative staphylococcus species. Biopsy showed acanthosis of epidermis with moderate lymphocytic infiltrates in dermis and focally a few neutrophils and histiocytes. Patient fulfilled the criteria for diagnosis of blastomycosis like pyoderma viz., presentation of large verrucous plaques with pustules and ulcers with elevated border, histologically neutrophilic infiltration and growth of one pathogenic bacterium on culture. Patient responded to long-term cefotaxime therapy.

Deep Fungal Infections, Blastomycosis-Like Pyoderma, and Granulomatous Sexually Transmitted Infections

Granulomatous diseases are caused by multiple infectious and noninfectious causes. Deep fungal infections can present in the skin or extracutaneously, most commonly with lung manifestations. An Azole or amphotericin B is the universal treatment. Blastomycosis-like pyoderma is a clinically similar condition, which is caused by a combination of hypersensitivity and immunosuppression. Successful treatment has been reported with antibiotics and, more recently, the vitamin A analog, acitretin. Granuloma inguinale and lymphogranuloma venereum cause ulcerative genital lesions with a granulomatous appearance on histology. The Centers for Disease Control and Prevention recommens treatment of these genital infections with doxycycline.