Cutaneous Kaposi sarcoma during treatment with superpotent topical steroids and methotrexate for bullous pemphigoid: three cases

Iatrogenic Kaposi sarcoma (KS) has previously been reported in patients with bullous pemphigoid (BP), in relation to systemic steroids. To report three cases of previously unreported cutaneous KS during treatment with superpotent topical steroids (STS) and methotrexate (MTX). All patients were elderly men with BP treated with STS for 2 to 32 months (cumulative doses: 2,700-9,150 g) before MTX was introduced (dosage: 10-12.5 mg/week). KS occurred one to nine months after the combined therapy. In one case, KS rapidly resolved after withdrawal of MTX. In two cases, vinblastine and/or radiotherapy were required to achieve regression of KS. Human herpes virus 8 (HHV8) latency-associated nuclear antigen was not expressed in BP lesions biopsied prior to development of KS (n = 3), but HHV8 DNA was detected in BP lesions from the patient with the most aggressive KS. Several predisposing factors were identified, including sex and age, high cumulative doses of STS, combination with MTX, and impaired immune status. In such cases, serum antibodies against HHV8 infection may be investigated in BP patients before introduction of MTX in order to guide clinical monitoring.

[High-resolution ultrasonography for differential diagnosis between nodular basal carcinoma and sebaceous hyperplasia of the face: A pilot study]

BACKGROUND

Clinical differential diagnosis between incipient nodular basal carcinoma (NBC) and sebaceous hyperplasia (SH) of the face is difficult in some cases. A comparative histological analysis of these two entities led us to the hypothesis that 20MHz high-resolution ultrasonography (HRUS) may enable differentiation between NBC and SH.

PATIENTS AND METHODS

Seventy-seven facial tumours requiring histological confirmation to distinguish between NBC and SH were scanned using HRUS before excision. No other imaging technique was used. The ultrasound scans were submitted to two blinded reviewers who were asked to classify the ultrasound pictures of the tumours as either hypoechoic or isoechoic/hyperechoic. Hypoechogenicity was defined as a diagnostic criterion for NBC.

RESULTS

Reviewer response reproducibility for 2 images of the same tumour was 90%. Both reviewers agreed regarding the echogenicity classification of an image in 87.4% of cases. The sensitivity of the procedure was 90.9% for detection of NBC and 89.4% for detection of malignant lesions. Specificity was 69.6% for detection of basal cell carcinomas and 78.8% for detection of malignant lesions.

DISCUSSION

HRUS is a non-invasive examination technique with excellent sensitivity for the detection of NBC in differential diagnosis with SH. Hypoechogenicity is not specific to NBC. The sensitivity of HRUS in our study suffered as a result of ultrasonography difficulties regarding unexpected differential diagnoses of NBC as well as tumour localisation in seborrhoeic areas.

[Treatment of superficial bacterial cutaneous infections: a survey among general practitioners in France]

BACKGROUND

Superficial bacterial skin infection and superinfection of skin diseases are usually treated by general practitioners using antiseptics or antibiotics. However, acquired resistance to biocidal agents, both systemic and topical, is growing.

OBJECTIVES OF THE STUDY

Our aim was to assess the skill of GPs in clinical situations involving common skin infections.

MATERIAL AND METHODS

On 16 June 2010, we sent a questionnaire to all GPs in a rural region of France (the Cher department) together with a stamped addressed envelope for the reply. The questionnaire contained seven pages of multiple-choice questions and five clinical cases, each one illustrated with a photograph (sty, furuncle, whitlow, colonized chronic wounds and impetigo). Anonymity of responses was guaranteed. Data was analysed using the Clinsight(®) software package.

RESULTS

The response rate was 51% (102 responses). GPs reported little difficulty in treating these patients (median 3, range 1 to 8 on a scale of increasing difficulty from 0 to 10). The main results of the study are firstly the frequency of combination of at least one antiseptic with one antibiotic (46%); secondly, the frequency of combination of two antibiotics (20% of cases); thirdly, the frequent prescription of systemic antibiotics for chronic wounds colonized by Pseudomonas aeruginosa (61%).

DISCUSSION

Our study shows the high frequency of prescriptions for combined therapy to treat superficial skin infections despite the fact that monotherapy with either an antiseptic or an antibiotic would probably suffice. It also shows the unnecessary prescription of antibiotics for colonization of a chronic wound. The study was limited in terms of size and design: it was a questionnaire rather than an analysis of prescriptions actually made in "real life", and the response rate was 51%. In addition, aside from impetigo, for which randomised studies and recommendations were given, the other surface infections (sty, folliculitis, whitlow) tend to be treated more empirically.

CONCLUSION

Dissemination of recommendations regarding the respective role of antiseptics and antibiotics (and their route of administration, topical or systemic) in superficial skin infections would doubtless be useful for prescribers, and more rational use of these agents would help limit bacterial resistance.

[Recurrent atypical mycobacterial infections in the adult: think of autoantibodies against interferon-gamma !]

INTRODUCTION

Disseminated non-tuberculosis mycobacterial infections are associated with a defect of the cellular immune response. They have been mainly reported in AIDS patients. Cases related to the presence of anti-interferon-γ autoantibodies are rare.

CASE REPORT

We report a non HIV-infected 45-year-old Thai woman, with a past medical history of Graves' disease. She presented with recurrent disseminated and severe non-tuberculous mycobacterial infections that were related to the production of anti-interferon-γ autoantibody. The diagnosis was suspected in the presence of a negative interferon-γ release assay (IGRA) including with the positive control, and evidenced by the identification of specific antibodies.

CONCLUSION

Anti-interferon-γ autoantibody production is a rare cause of non tuberculous mycobacterial infection. Such a mechanism should be suspected in non HIV-infected patients and especially in those having an Asiatic ethnicity or an associated immune disorder. A negative IGRA (including with the positive control) is a reliable diagnostic tool and should be completed with the identification of specific autoantibodies.