Pandora’s Box: Disseminated Coccidioidomycosis Associated with Self-Medication with an Unregulated Potent Corticosteroid Acquired in Mexico

Coccidioidomycosis (CM), caused by the dimorphic fungi Coccidioides immitis and C. posadasii, typically presents as acute or chronic pulmonary disease. However, disseminated disease occurs in about 1% of patients. Disseminated CM may affect multiple organ systems, including cutaneous, osteoarticular, and central nervous system sites. Here, we present a case of disseminated CM in a patient from a border city in Texas. The patient had a history of uncontrolled diabetes mellitus and was also taking an over-the-counter medication acquired in Mexico that contained a potent corticosteroid. The patient presented with seizures and was found to have a brain infarct, cavitary lung lesions, synovitis of the knee, multiple skin lesions, and chorioretinitis. The patient had a very high complement fixation titer for Coccidioides; fungal spherules were seen in a skin biopsy specimen, and Coccidioides grew in culture from a sample of synovial fluid and the skin biopsy specimen. This case illustrates the dissemination potential of Coccidioides, the danger of unregulated pharmaceuticals, the importance of thorough history taking, and recognizing risk factors that contribute to disseminated CM.

Dominance of Methicillin-Resistant Staphylococcus aureus in a Japanese Infant with Recessive Dystrophic Epidermolysis Bullosa

A male infant had the very fragile skin and easily formed bullas by rubbing and scratching from his birth. He was diagnosed with severe recessive dystrophic epidermolysis bullosa (RDEB) due to the lack of type VII collagen by performing an immunofluorescence mapping method from a skin biopsy specimen of the patient’s bulla. We analyzed the skin microbiome using next-generation sequencer. The species from the patient’s skin revealed the dominance of <i>Staphylococcus aureus</i> (<i>S. aureus</i>) similar to the reports from Austria and Chile severe RDEB patients, and these results are same as the pattern isolated from the skin of atopic dermatitis (AD) patients with flares. The interaction of microbiome and skin microenvironment may be similar between RDEB and AD worldwide.

Reactivation of Chagas Disease in a Patient With an Autoimmune Rheumatic Disease: Case Report and Review of the Literature

Reactivation of Chagas disease has been described in immunosuppressed patients, but there is a paucity of literature describing reactivation in patients on immunosuppressive therapies for the treatment of autoimmune rheumatic diseases. We describe a case of Chagas disease reactivation in a woman taking azathioprine and prednisone for limited cutaneous systemic sclerosis (lcSSc). Reactivation manifested as indurated and erythematous cutaneous nodules. Sequencing of a skin biopsy specimen confirmed the diagnosis of Chagas disease. She was treated with benznidazole with clinical improvement in the cutaneous lesions. However, her clinical course was complicated and included disseminated CMV disease and subsequent septic shock due to bacteremia. Our case and review of the literature highlight that screening for Chagas disease should be strongly considered for patients who will undergo immunosuppression for treatment of autoimmune disease if epidemiologically indicated.

Outlooks of synthetic mycobacterial antigens in serological diagnostics of leprosy

Despite the fact that the incidence of leprosy in Russia is sporadic, the number of newly identified patients has increased in recent years. In 2017–2018, 4 new cases of leprosy were registered in Russia. The standard methods of research for diagnosis, in addition to the clinical picture, are bacterioscopic study of the skin scarificates and histological study of the skin biopsy specimen. Currently, additional methods are being developed and used to confirm the diagnosis of leprosy, namely, modern serological and genetic diagnostic methods. To use methods such as enzyme-linked immunosorbent assay (ELISA) and membrane immunochromatographic analysis (leprosy LF serotest), it is appropriate to use domestic synthetic mycobacterial antigens (SMA). Key words: Mycobacterium leprae, leprosy, synthetic mycobacterial antigens, PGL-1(phenolic glycolipid-1), LAM (lipoarabinomannan), serodiagnostics, enzyme-linked immunosorbent assay (ELISA), lateral flow (LF) test, BSA (bovine serum albumin)

Lymphocutaneous Sporotrichosis in a Patient with Underlying Systemic Lupus Erythematosus

Sporotrichosis is a globally prevalent subcutaneous mycosis commonly acquired through traumatic inoculation. A 66-year-old woman with underlying systemic lupus erythematosus (SLE) presented initially with a painful non-healing nodule on her right thumb. There was no history of traumatic contact with soil, plants or animals. She was started on an antibiotic but developed multiple nodules on her right forearm which appeared to spread proximally. Culture of her skin biopsy specimen yielded Sporothrix schenckii. The lesions were successfully treated with oral itraconazole. In conclusion, a history of traumatic inoculation need not always be present in SLE patients with sporotrichosis and obtaining a laboratory diagnosis is crucial for those presenting with nodular skin lesions that spread proximally J MEDICINE JAN 2020; 21 (1) : 59-61

HISTOPATHOLOGICAL AND IMMUNOFLUORESCENT STUDIES IN CERTAIN SKIN DISORDERS

Background: This study was an attempt to evaluate the role of direct immunofluorescent technique to demonstrate the immunoglobulins in certain skin disorders, which are likely to have immunological mechanism in their pathogenesis. Methods: This study was carried out in department of Pathology, Sardar Patel Medical College & Associated group of Hospitals, Bikaner. This study was hospital based study on skin biopsy specimen recieved in the department of Pathology during the study period. Results: On immunofluorescent studies of these skin biopsies, 12 out of 16 cases of pemphigus were positive for fluorescence was intracellular area in epidermis. In lichen planus 5 out of 7 cases were positive for fluorescence and commonest site was dermo-epideremal junction. In dermatis-herpatiformis 2 out of 3cases were positive for fluorescence and commonest site was dermo-epideremal junction. IgG was commonest type of immunoglobulin’s demonstrate in 12 out of 16 cases of pemphigus followed by IgM (5 cases), IgA(1cases). In lichen planus IgM was commonest type of immunoglobulin’s demonstrate in 5 out of 7 cases of pemphigus followed by IgG (3 cases), IgA(1cases). In dermatitis herpatiformis IgA was commonest type of immunoglobulin’s demonstrate in 2 out of 3 cases of pemphigus followed by IgM (1 cases). Conclusion: We conclude that the demonstration of immunoglobulins in skin biopsies by direct fluorescent technique is a quite useful adjunct in diagnostic confirmation of pemphigus, lichen planus and dermatitis herpetiformis. Keywords: Direct immunofluorescence, Pemphigus, Histopathology.