Blastomycosis-like pyoderma in a case of chronic myeloid leukaemia

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 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.

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.

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.

Blastomycosis-like Pyoderma with Good Response to Acitretin

Blastomycosis-like pyoderma is a rare, vegetating skin lesion that is an unusual exaggerated tissue reaction possibly to prolonged primary or secondary bacterial infection. We report a case of blastomycosis-like pyoderma in a man with Down syndrome, diabetes mellitus and hypothyroidism who responsed poorly to conventional therapies, including antibiotics and correction of predisposing factors for a long time, but experienced dramatic improvement after 3 months of acitretin treatment.

Pyoderma vegetans associated with severe psoriatic arthritis: good response to etanercept

Pyoderma vegetans (PV) is an inflammatory dermatosis, characterized clinically by large exudative vegetating plaques, and histopathologically by epidermal pseudoepitheliomatous hyperplasia and dense inflammatory infiltrates. Although PV is a very rare condition, it is a chronic disorder that may accompany any systemic process that compromises immunity. Treatment is very difficult, and correction of predisposing causes may be useful. We present a 49-year-old woman affected by severe psoriatic arthritis since she was 19, with giant verrucous plaques on her lower limbs that had worsened progressively during the last 15 years. After ruling out other vegetating cutaneous disorders, PV was diagnosed in association with psoriasis. Despite numerous previous systemic and topical therapeutic attempts no response was observed. Etanercept was introduced, which resulted in a marked improvement within 3 weeks. Herein, we report a diagnostic and therapeutic challenge of the first case of PV associated with psoriasis that presented a good response to etanercept.

Blastomycosis-like pyoderma: Successful treatment with low-dose acitretin

Blastomycosis-like pyoderma typically presents as verrucous plaque(s) with a purulent discharge through multiple sinuses. Two patients with blastomycosis-like pyoderma developing on significantly sun-damaged skin are presented: an 84-year-old man with multiple painful nodules and plaques, and a 92-year-old woman with a solitary plaque on the left calf. Histopathology showed pseudoepitheliomatous hyperplasia with dermal foci of suppuration. Staphylococcus aureus was isolated from a biopsy specimen in the first patient, whereas the latter patient had Prevotella and Corynebacterium species. Investigations for fungi and mycobacteria yielded negative results. These microbiological findings further supported the clinicopathological diagnosis. Both patients failed to respond to oral doxycycline despite the in vitro susceptibility of the organisms. Treatment with low-dose oral acitretin was successful in both patients after 3-4 months.

Localized blastomycosis-like pyoderma with good response to cotrimoxazol and cryotherapy

Blastomycosis-like pyoderma is an unusual, exaggerated, vegetative-tissue reaction to a prolonged primary or secondary bacterial infection. It is a rare disease, usually seen in immunocompromized patients. We report a case of localized blastomycosis-like pyoderma responding poorly to classic treatments, but that gave a dramatic response to a combination treatment of cotrimoxazol and cryotherapy.