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Fig 2. Clavi syphilitici. Clinical appearance of palmarlesions 1 month after penicillin treatment.
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was observed after the penicillin treatment (Fig 2).The patient underwent proctologic examination,which showed no further alterations in addition toperianal condyloma acuminata, and cryosurgery ofthose lesions was performed.
The multiple and atypical manifestations ofsecondary syphilis in patients with HIV may resultin a misdiagnosis and inappropriate treatment.
In the literature, there are few reports of palmarand plantar hyperkeratotic lesions of secondarysyphilis,3,4 some of which can mimic and beconfused with viral warts or calluses, classicallyknown as clavi syphilitici.5
In the described case, the combination ofpalmar-plantar lesions, detection of Treponemapallidum by molecular biology, positive serologyfor syphilis, and rapid response to treatment withpenicillin was consistent with a diagnosis of sec-ondary syphilis.
We present this case to illustrate a rare andpotentially confounding clinical manifestation ofsyphilis, a disease that is still very present in medicalpractice. We also intend to emphasize that theacquisition of another sexually transmitted infection(STI) by a patient with HIV is a public health problembecause it means the maintenance of risk behaviorsthat enhance the transmission of these diseases. Forthe patient, the infection with an STI is a risk factorfor other STIs, so in individuals with HIV, syphilisshould be included in the differential diagnosis ofnew skin and mucosal lesions or those unresponsiveto conventional therapy.
Catarina Moreira, MD,a Ana F. Pedrosa, MD,a
Carmen Lisboa, PhD,a,b and Filomena Azevedo,MDa
Department of Dermatology and Venereology,a
Centro Hospitalar S~ao Jo~ao EPE, and Faculty ofMedicine,b University of Porto, Portugal
Funding sources: None.Open access under CC BY-NC-ND license.
Conflict of interest: None declared.
Corresponding author: Catarina Moreira, MD,Department of Dermatology and Venereology,Centro Hospitalar S~ao Jo~ao EPE, Porto, Portugal
E-mail: [email protected]
REFERENCES
1. Domantay-Apostol GP, Handog EB, Gabriel MT. Syphilis: the
international challenge of the great imitator. Dermatol Clin
2008;26:191-202.
2. Gregory N, Sanchez M, Buchness MR. The spectrum of syphilis
in patients with human immunodeficiency virus infection. J Am
Acad Dermatol 1990;22:1061-7.
3. Kishimoto M, Lee MJ, Mor A, Abeles AM, Solomon G, Pillinger
MH. Syphilis mimicking Reiter’s syndrome in an HIV-positive
patient. Am J Med Sci 2006;332:90-2.
4. Shinkuma S, Abe R, Nishimura M, Natsuga K, Fujita Y, Nomura T,
et al. Secondary syphilis mimicking warts in an HIV-positive
patient. Sex Transm Infect 2009;85:484.
5. Lewin G. Clavi syphilitici. Archiv f€ur Dermatologie und Syphilis
1893;25(1):3-34.
http://dx.doi.org/10.1016/j.jaad.2013.09.025
A case of lipoatrophy following quadrivalenthuman papillomavirus vaccine administration
To the Editor: Lipoatrophy is a localized loss ofsubcutaneous adipose tissue without significantinflammation.1 Acquired forms result from physicaltrauma (cold, trauma, factitious insults) or fromcontact with noxious chemicals.2 It is a commonreaction at the level of injection sites and couldappear at a distant site months or years after theinjection.
Several drugs have been implicated, includinginsulin and insulin analogs in diabetes, glatirameracetate in multiple sclerosis, corticosteroids, vaso-pressin, antibiotics, human growth hormone, irondextran, diphtheria-pertussis-tetanus immunizationserum, and antihistamines.1
We report a case of lipoatrophy that could beassociated with injection of prophylactic quadriva-lent human papillomavirus vaccine Gardasil.
A 27-year-old woman presented to the derma-tology clinic with a circular depression on her rightarm without any local symptoms or previous inflam-mation. She had no medical problems and was nottaking any medication. She reported a history of 3intramuscular Gardasil injections on a 0-, 2-, and6-month-schedule in the same arm, with the lastinjection given 9 months before the appearance ofthe lesion. The patient denied any other injection( foreign body or steroids) or trauma to the involvedarm. Physical examination revealed a soft, non-tender, 8- 3 5-cm skin depression. The patient also
Fig 1. Lipoatrophy. Soft, nontender, 8-3 5-cm skindepression over right arm.
Fig 2. Lipoatrophy. Macrophagic infiltration within grayishgranulations compatible with aluminum granuloma.
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had a burn scar on the anterior aspect of the armsince childhood (Fig 1).
Laboratory studies including complete bloodcount, serum glucose, lipase, cholesterol, triglycer-ides, and complement level, as well as renal andhepatic parameters, antinuclear antibody, ds-DNA,and U1RNP were within normal range.
Magnetic resonance imaging of the arm showedatrophy of the subcutaneous fat facing the postero-lateral fibers of the medial third of the deltoid musclewith adherence of the muscle to the skin. There wasno evidence of any expansive process or fat infiltra-tion of the muscle.
A biopsy was performed to rule out lupuspanniculitis, scleroderma, and cutaneous T-cell lym-phoma. Histology with immunofluorescenceshowed small adipocytes in the hypodermis withlipophages and some lymphocytes surrounded byfibrosis compatible with lipoatrophy. Deep cutsshowed macrophagic infiltration within whichgrayish granulations exist, an image compatiblewith aluminum granuloma (Fig 2).
Each dose of Gardasil contains HPV 6, 11, 16,and 18 with amorphous aluminium hydroxyphos-phate sulphate as adjuvant.3 The latter is used in
multiple vaccines such as tetanus toxoid, hepatitisB, and diphtheria-pertussis-tetanus and in allergenimmunotherapy with the aim of prolonging andaugmenting the immune response to the antigen.4 Itis known to cause aluminium granuloma with adiverse range of histologic reaction patterns.4
Atrophy and fibrosis of subcutaneous fat havebeen described by Chong and colleagues.4 Thehistologic features in our case are more indicative ofa foreign body reaction to aluminium hydroxidethan of an allergic reaction.5
To our knowledge, lipoatrophy following injec-tion of the quadrivalent human papillomavirus vac-cine Gardasil has not been described before. We didnot find in this case any other cause that could berelated to lipoatrophy unless trauma of the injectionitself is an etiology.2 We estimate that the injectionwas subcutaneous instead of intramuscular and thatthe aluminium granulations found in the macro-phages correspond to the adjuvant found in thevaccine.
Farid St�ephan, MD,a Joelle Korkomaz, MD,a
Gerard Abadjian, MD,b Jad Okais, MD,c andRoland Tomb, PhDa
Department of Dermatology,a Department ofPathology,b and Department of Rhumatology,c
Hotel Dieu de France University Hospital, Beirut,Lebanon - Faculty of Medicine, Saint JosephUniversity, Beirut, Lebanon
Funding sources: None.
Conflict of interest: None declared.
Correspondence to: Joelle Korkomaz, MD, Depart-ment of Dermatology, Hotel Dieu de FranceUniversity Hospital, Beirut, Lebanon - Facultyof Medicine, Saint Joseph University, Beirut,Lebanon
E-mail: [email protected]
REFERENCES
1. So�os N, Shakery K, Mrowietz U. Localized panniculitis and
subsequent lipoatrophy with subcutaneous glatiramer acetate
(Copaxone) injection for the treatment of multiple sclerosis. Am
J Clin Dermatol 2004;5:357-9.
2. Haas N, Henz BM, Bunikowski R, Keitzer R. Semicircular lipoa-
trophy in a child with systemic lupus erythematosus after
subcutaneous injections with methotrexate. Pediatr Dermatol
2002;19:432-5.
3. Crum C, Jones C, Kirkpatrick P. Fresh from the pipeline:
quadrivalent human papillomavirus recombinant vaccine. Nat
Rev Drug Discovery 2006;5:629-30.
4. Chong H, Brady K, Metze D, Calonje E. Persistent nodules at
injection sites (aluminium granuloma) e clinicopathological
study of 14 cases with a diverse range of histological reaction
patterns. Histopathology 2006;48:182-8.
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5. Vogelbruch M, Nuss B, K€orner M, Kapp A, Kiehl P, Bohm W.
Aluminium-induced granulomas after inaccurate intradermal
hyposensitization injections of aluminium-adsorbed depot
preparations. Allergy 2000;55:883-7.
http://dx.doi.org/10.1016/j.jaad.2013.09.038
Fig 1. Mycobacterium fortuitum infection associated withacupoint embedding therapy. Multiple tender, erythema-tous nodules with a linear distribution on the lower aspectof right cheek and around the nasolabial fold.
Fig 2. Mycobacterium fortuitum infection associated withacupoint embedding therapy. Acute mixed inflammationcomposed of lymphocytes, neutrophils, and histiocytesinvolving the entire dermis. (Hematoxylin-eosin stain;original magnification: 3100).
Infection with Mycobacterium fortuitumduring acupoint embedding therapy
To the Editor: Acupoint embedding therapy (AET),also known as needle embedding therapy, embedsabsorbable foreign substances such as polydioxa-none sutures in acupoints to achieve their long-termstimulation. AET has been used to treat chronic andpainful disorders, particularly in traditional orientalmedicine,1 and is currently also used for aestheticpurposes (eg, reducing facial wrinkles). However,little is known about the adverse effects of thistherapy. Here, we report a patient with nontubercu-lous mycobacteria (NTM) infection induced by AET.
A healthy 44-year-old woman presented withmultiple tender erythematous papules and noduleson both cheeks (Fig 1). She had recently undergone2 courses of AET separated by an interval of 1 month.Needles were used to embed sterile polydioxanonesutures in acupoints of lower aspects of both cheeksand nasolabial folds. After the second course,multiple oozing erythematous papules and tendernodules appeared, the locations of which corres-ponded with the points at which the sutures hadbeen embedded. The patient did not have a fever orlymphadenopathy, and responded poorly toacupuncture performed by the oriental medicinedoctors who performed the AET. The patient under-went a 1-month course of combined minocyclineand cefixime therapy at another dermatology clinic.A skin biopsy specimen revealed a dermal abscesscomprising lymphocytes, neutrophils, and histio-cytes without foreign body granulomas or suturematerials (Fig 2). Dermal tissue culture revealedatypical mycobacteria, which were identified asMycobacterium fortuitum by polymerase chainreaction hybridization using the rpoB gene.The isolate was susceptible to doxycycline,ciprofloxacin, amikacin, and clarithromycin. Thepatient responded well to combination therapywith oral doxycycline, ciprofloxacin, and clarithro-mycin. After 3 months of treatment, the lesionscontinued to improve and a 6- to 12-month courseof combination therapy was recommended.
AET is thought to work by inducing the release ofneurochemicals in response to the application ofpressure or needles to acupoints.1 AET is increas-ingly used for gradual face lifts and skin tightening,especially among oriental medicine doctors in
Korea. AET is advertised as a nonsurgical procedurethat uses natural materials; therefore, many patientsassume it is safer than filler or botulinum toxintreatments. However, AET can cause iatrogenicinfections.
As with other strains of NTM, M fortuitum in-fections are generally associated with the use ofcontaminated solutions and/or equipment duringmedical procedures. In the case presented here, thesource of contamination responsible for the NTMinfection could not be identified. However, becausedisposable needles and threads were used, wesuspected that mycobacteria on the patient’s skinmay have been the source of the infection. Thepatient was treated with minocycline, which mighthave a lower benefit/risk ratio than doxycycline.2
Until the causative organisms are isolated, empiricalantibiotics should be used carefully.
