Zoon Balanitis and Lichen Sclerosus: An Uncommon Association

Zoon balanitis and lichen sclerosus are both chronic inflammatory disorders of the genital mucosa that usually affect middle-aged or elderly uncircumcised men.Although the precise etiology of Zoon balanitis is still unclear, a pathogenic role of irritant and mechanical factors has been suggested. Therefore, foreskin sclerosis and phimosis caused by male genital lichen sclerosus may trigger the development of Zoon balanitis. However, until the present, only three cases with clinical and histopathologic features consistent with synchronous presentation of both disorders have been described. We report the case of a 70-year-old male who developed Zoon balanitis in association with lichen sclerosus, that cleared only after circumcision.

RAPID DEVELOPMENT OF IATROGENIC CUSHING SYNDROME IN A PATIENT ON RITONAVIR: THE ADVERSE METABOLIC CONSEQUENCE OF TOPICAL STEROID USE

Objective: Topical steroid use is common, but its association with Cushing syndrome is rare. We report the rapid development of iatrogenic Cushing syndrome in a patient on ritonavir who applied a moderate-potency topical steroid cream, triamcinolone, on his genital mucosa for treatment of phimosis. Methods: Clinical and diagnostic challenges associated with topical steroid use are presented and discussed. Results: A 41-year-old man with human immunodeficiency virus infection on stable antiretroviral therapy that included ritonavir, a cytochrome P450 3A4 inhibitor, presented with new onset diabetes and development of overt cushingoid features over a 4-week period. He reported no known history of steroid use. A midnight salivary cortisol using a quantitative enzyme immunoassay was obtained and reported at >15.0 μg/dL (normal, <0.112 μg/dL). However, free cortisol in a 24-hour urine collection was undetectable by high-performance liquid chromatography and morning plasma cortisol was also unexpectedly low at 1.1 μg/dL (normal, 4.5 to 23.0 μg/dL). Further investigation revealed that the patient had been applying a topical cream with triamcinolone acetonide (0.1%) on the glans penis for treatment of phimosis. The salivary enzyme immunoassay for cortisol appears to have detected the absorbed triamcinolone, a compound known to cross-react with cortisol in this assay. Conclusion: This case raises awareness on the severe metabolic consequence resulting from the seemingly benign use of a topical steroid medication when applied to the genital mucosa in the setting of stable therapy with ritonavir and illustrates the limitations of salivary cortisol enzyme immunoassays for the evaluation of Cushing syndrome in this setting.

Incomplete Stevens-Johnson Syndrome Caused by Sulfonamide Antimicrobial Exposure

Stevens-Johnson syndrome (SJS) is a mucocutaneous reaction typically brought on by medications or infections. The diagnosis of SJS is typically made when patients present with a variable appearing rash and involvement of the oral, ocular, or genital mucosa. However, there are rare reports of atypical or incomplete SJS. These cases are usually associated with children infected with Mycoplasma pneumoniae, which presents with severe mucositis but no rash. Herein, we report the first case of adult incomplete SJS brought on by sulfonamide antimicrobial use without clinical or laboratory evidence of M. pneumoniae infection.