Cutaneous nontuberculous mycobacteria infections: A retrospective case series of 78 patients from the Texas Gulf Coast region.

BACKGROUND: The incidence of cutaneous nontuberculous mycobacteria (NTM) infections is increasing. These infections are a diagnostic and therapeutic challenge. OBJECTIVE: We investigated the clinical features, diagnosis, and management of cutaneous NTM infections. METHODS: A retrospective case series studied 78 patients from a Gulf Coast tertiary referral center diagnosed with cutaneous NTM infection by culture or stain of a skin biopsy specimen. RESULTS: A history of trauma, procedure, or environmental exposure was common. The mean time between the initial evaluation and diagnosis was 12 weeks. Only 15% of acid-fast bacillus-positive cultures had a positive acid-fast bacillus smear, and only 43% of those accompanied by skin biopsy specimen had a positive Fite stain. Immunosuppressed patients were more likely to have a positive Fite stain. Treatment included surgery and multiple antibiotics. Immunosuppressed patients and Mycobacterium abscessus group infections were more likely to have persistent disease. LIMITATIONS: M chelonae and M abscessus isolates were indistinguishable and therefore were reported together. Five cases were not confirmed by culture. CONCLUSIONS: Even with clinical suspicion, the diagnosis of NTM infection can be difficult. Results of acid-fast bacillus smears and special stains are frequently negative. Antibiotic resistance is common. Multidrug treatment is often required, and surgical therapy may be needed.

Primary cutaneous histiocytoid carcinoma with distant metastasis.

Distinguishing primary cutaneous adnexal carcinoma from metastatic carcinoma of unknown primary can be a diagnostic challenge due to the frequent overlap of histologic and immunohistochemical features. A 58-year-old man presented with a tender, indurated plaque on axillary skin. Biopsy revealed infiltrating atypical cells throughout the dermis, without connection to the epidermis. Tumor cells had a histiocytoid appearance and displayed mild pleomorphism. The tumor was discohesive and had areas with a single file pattern. Signet ring cells were also present. Cells were reactive with CK7, CK5/6, p63, GATA3, GCDFP-15 and Her 2-neu. Additional studies were negative, including TTF-1, CDX2, E-cadherin, mammaglobin, estrogen receptor and progesterone receptor. Thorough clinical and radiologic evaluation failed to identify an occult primary extracutaneous malignancy; however, regional lymphadenopathy, widespread osteoblastic lesions and multiple subcentimeter liver hypodensities were noted. Considering the clinical and histopathologic features, the diagnosis of primary cutaneous histiocytoid carcinoma with distant metastasis was favored.

Pregnancy-specific skin disorders.

The pregnancy-specific skin disorders are pruritic, inflammatory eruptions. The current classification by Ambros-Rudolph et al. includes four entities: pemphigoid gestationis (PG), polymorphic eruption of pregnancy (PEP), atopic eruption of pregnancy (AEP), and intrahepatic cholestasis of pregnancy (ICP). Although these disorders are all characterized by intense pruritus during pregnancy, they can be distinguished by timing, morphology, histopathology, treatment and potential for fetal complications. Diagnosis is made by clinical presentation, histology, and immunofluorescence. PEP and AEP typically resolve without sequelae; however, PG may lead to prematurity and low birth weight, and ICP is associated with an increased risk of prematurity, fetal distress, and intrauterine fetal demise. The potential for serious fetal complications necessitates a thorough evaluation of pregnancy-related pruritus. This article will discuss the skin disorders specific to pregnancy, with a focus on clinical presentation, potential for fetal complications, pathogenesis, diagnosis, and treatment.

Mycobacterium fortuitum infection arising in a new tattoo.

We report an uncommon case of a cutaneous infection with Mycobacterium fortuitum arising in a new tattoo. A 29-year-old man presented with a several month history of a non-pruritic papular eruption within a tattoo; the papules developed 1-to-2 weeks after the tattoo procedure. He denied similar symptoms with previous tattoos. He had been treated unsuccessfully with cephalexin. Histopathologic examination revealed perifollicular chronic and granulomatous inflammation, consistent with chronic folliculitis. Acid-fast bacilli culture identified Mycobacterium fortuitum complex. The patient was treated with a 2-month course of oral trimethoprim-sulfamethoxazole (160mg/800mg twice daily) and ciprofloxacin (250 mg twice daily), with clinical improvement at follow up after three weeks of the antibiotic regimen. Rapidly growing mycobacteria have emerged as a cause of tattoo-associated cutaneous infection in recent years. Diagnosis and treatment can be difficult without clinical suspicion. M. fortuitum and other rapidly growing mycobacteria should be considered in the differential diagnosis of tattoo-associated dermatologic complications.

Co-occurring anammox, denitrification, and codenitrification in agricultural soils.

Anammox and denitrification mediated by bacteria are known to be the major microbial processes converting fixed N to N(2) gas in various ecosystems. Codenitrification and denitrification by fungi are additional pathways producing N(2) in soils. However, fungal codenitrification and denitrification have not been well investigated in agricultural soils. To evaluate bacterial and fungal processes contributing to N(2) production, molecular and (15)N isotope analyses were conducted with soil samples collected at six different agricultural fields in the United States. Denitrifying and anammox bacterial abundances were measured based on quantitative PCR (qPCR) of nitrous oxide reductase (nosZ) and hydrazine oxidase (hzo) genes, respectively, while the internal transcribed spacer (ITS) of Fusarium oxysporum was quantified to estimate the abundance of codenitrifying and denitrifying fungi. (15)N tracer incubation experiments with (15)NO(3)(-) or (15)NH(4)(+) addition were conducted to measure the N(2) production rates from anammox, denitrification, and codenitrification. Soil incubation experiments with antibiotic treatments were also used to differentiate between fungal and bacterial N(2) production rates in soil samples. Denitrifying bacteria were found to be the most abundant, followed by F. oxysporum based on the qPCR assays. The potential denitrification rates by bacteria and fungi ranged from 4.118 to 42.121 nmol N(2)-N g(-1) day(-1), while the combined potential rates of anammox and codenitrification ranged from 2.796 to 147.711 nmol N(2)-N g(-1) day(-1). Soil incubation experiments with antibiotics indicated that fungal codenitrification was the primary process contributing to N(2) production in the North Carolina soil. This study clearly demonstrates the importance of fungal processes in the agricultural N cycle.

Cosmetic dermatology training in residency: results of a survey from the residents' perspective.

BACKGROUND: Dermatologists are expected to be experts in the evaluation and treatment of their patient's cosmetic concerns. It has been reported that some dermatology residents do not feel adequately trained in this field. OBJECTIVE: To assess how dermatology residents are being trained in cosmetic dermatology. METHODS: A survey was e-mailed to 473 third-year dermatology residents. RESULTS: One hundred eighteen surveys were returned (24.9%), representing 45% of programs. Most residents have assigned reading (70.7%) and lectures (81.4%) in cosmetic dermatology. To learn technical skills, 79.7% participate in formal training sessions, and 73% have an apprenticeship model. Most residents have the opportunity to perform botulinum toxin injections, laser surgery, fillers, chemical peels, and sclerotherapy. More than 58% of programs have an encouraging or somewhat encouraging attitude toward teaching cosmetics, whereas 22% were somewhat discouraging or discouraging. Most residents (75.4%) plan to incorporate cosmetics into their practice. Residents do not feel less prepared (94.9%) or less interested (97.4%) in medical dermatology as a result of their cosmetic training. CONCLUSIONS: Residents are being trained in cosmetic dermatology through a variety of methods. Residency programs should periodically assess and adapt their curricula to ensure adequate training in this field.

HIV photodermatitis presenting with widespread vitiligo-like depigmentation.

HIV photodermatitis encompasses a variety of clinical manifestations. We report a rare clinical presentation of HIV photodermatitis with widespread vitiligo-like depigmentation.

The "away" dermatology elective for visiting medical students: Educational opportunities and barriers.

Dermatology electives allow medical students an opportunity to explore the field of dermatology. In order to gain greater exposure to the specialty of dermatology, some medical students have an interest in taking "away" dermatology electives at other U.S. medical schools. A telephone survey was conducted to better understand the opportunities and barriers that exist for visiting medical students to take an elective in dermatology. Areas of focus in the survey included dermatology elective offerings, institutional policies toward visiting students, academic requirements for visiting students, timing of electives, financial costs of electives incurred by the student and institutional and regional preferences of the host medical school. Survey results indicated considerable opportunities for medical students to explore the field of dermatology among U.S. medical schools, but variance among schools regarding the number and types of dermatology electives offered. Medical schools with dermatology residencies were statistically more likely to offer dermatology electives to visiting medical students than those that did not (p<0.0001). Students from schools that do not provide more advanced electives may find it difficult to explore the field beyond a general dermatology elective because of the limited availability of subspecialty elective rotations for visiting students. Other barriers for "away" electives include academic requirements, priority in course registration for a school's own students, differing rotation schedules, and additional financial costs.