An atypical presentation of a Pasteurella multocida infection following a cat bite: a case report.

Pasteurella multocida is a bacterial organism that commonly causes cellulitis after animal bites, especially cat bites. We report an unusual vesiculopustular infection of the hand following a domestic cat bite. Pasteurella multocida and Staphylococcus aureus were cultured from the wound and the patient was treated with amoxicillin-clavulanate potassium. Further history revealed that the patient's cat had nibbled on her hand. Pasteurella usually is resistant to many of the typical empiric antibiotics used to treat skin infections. Amoxicillin-clavulanate potassium (500 mg 3 times daily) is the treatment of choice for patients who have an infected cat or dog bite with no known bacterial cause. A thorough patient history is needed to promptly arrive at a proper diagnosis for an atypical presentation of a common disease.

The cutaneous and systemic manifestations of azathioprine hypersensitivity syndrome.

BACKGROUND: Azathioprine (AZA) hypersensitivity syndrome is a rare side effect that typically occurs early in the initiation of therapy and may include a cutaneous eruption. It is often under-recognized because it mimics infection or disease exacerbation. Until recently, the cutaneous findings associated with AZA hypersensitivity have been reported using nonspecific, descriptive terms without a supportive diagnostic biopsy. OBJECTIVE: To characterize the cutaneous and histologic findings associated with AZA hypersensitivity syndrome. METHODS: We conducted a retrospective analysis of two cases of AZA hypersensitivity syndrome and describe the cutaneous manifestations and histological findings of each case. A review of the English literature for cases of AZA hypersensitivity or allergic or adverse reactions associated with AZA was performed. RESULTS: Sixty-seven cases of AZA hypersensitivity were reviewed; 49% (33/67) had cutaneous manifestations. Of those cases presenting with cutaneous findings, 76% (25/33) had biopsy results or clinical features consistent with a neutrophilic dermatosis, whereas the other 24% (8/33) were reported as a nonspecific cutaneous eruption. LIMITATIONS: Only case reports in which the skin findings could be classified were reviewed. CONCLUSIONS: The predominant cutaneous reaction reported in the literature and observed in the present case series is a neutrophilic dermatosis. Hypersensitivity to AZA can manifest along a wide clinical spectrum from local neutrophilic disease to a systemic syndrome. Skin findings may be an important early clue to the diagnosis of AZA hypersensitivity and aid in prompt recognition and treatment of this potentially life-threatening adverse drug effect.

Cyclosporine for SJS/TEN: a case series and review of the literature.

Clear guidelines for the treatment of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are lacking due to its infrequency and the absence of large controlled studies. Systemic corticosteroids and intravenous immunoglobulin (IVIG) have received considerable attention, though reports of the use of these agents have demonstrated mixed success rates in improving morbidity and mortality from SJS/TEN. We present a case series of 4 patients with SJS/TEN who rapidly responded to treatment with cyclosporin A (CsA). We discuss the proposed mechanism of action and the rationale for the use of cyclosporin based on the currently understood pathophysiologic mechanism of TEN.

Permanent press allergy in an active duty U.S. Army soldier.

Ethylene urea/melamine formaldehyde resin (permanent press) is a common fabric finishing agent added to Army Combat Uniforms for a wrinkle-free appearance and to strengthen the fabric. We describe the case of an active duty U.S. Army soldier with a diffuse eczematous dermatitis in whom patch testing was used to identify an allergy to permanent press, a ubiquitous fabric finishing agent in the Army combat uniform. To our knowledge, this is the first case report of a soldier with an allergic contact dermatitis to ethylene urea/melamine formaldehyde resin. This case highlights the importance of considering the diagnosis of allergic contact dermatitis in patients with a recurrent eczematous dermatitis that does not respond appropriately to therapy and the unique occupational impact of diagnosing an Army soldier with permanent press allergy.

Contribution of dermatologic surgery in war.

BACKGROUND: Despite the large contribution by dermatology to military readiness, there have been no published reports regarding dermatologic surgery or skin cancer in the combat environment. OBJECTIVE: To outline the contribution of dermatologic surgery, including skin cancer and benign tumors, to deployed service men and women in Operation Iraqi Freedom. METHODS: A retrospective chart review was performed of all dermatology visits at the 86th Combat Support Hospital, Ibn Sina, Iraq, between January 15, 2008 and July 15, 2008. RESULTS: Two thousand six hundred ninety-six patients were seen in the combat dermatology clinic during the 6-month period reviewed; 8% (205/2,696) of the total visits were for skin cancer, and another 129 patients were treated for actinic keratosis. The specific diagnoses were basal cell carcinoma (n=70), in situ and invasive squamous cell carcinoma (n=68), mycosis fungoides (n=1), bowenoid papulosis (n=1), and in situ and invasive melanoma (n=9). Benign lesions and tumors accounted for 14% (357/2,696) of total patient visits. Three hundred seven surgeries were performed during the 6-month period (178 skin cancers and 129 benign lesions), and 20 patients were referred for Mohs micrographic surgery. The surgical complications included five postoperative wound infections (1 methicillin-resistant Staphylococcus aureus), one wound dehiscence, and seven allergic contact dermatitis. CONCLUSIONS: To the authors' knowledge, this is the first publication regarding skin cancer and dermatologic surgery in the combat setting. This report outlines the important contribution of dermatologic surgery in the combat environment.

Combat dermatology: the prevalence of skin disease in a deployed dermatology clinic in Iraq.

BACKGROUND: Since July 2004, the United States (U.S.) Army has operated a forward-deployed dermatology clinic in Baghdad, Iraq. This paper outlines the prevalence of skin disease among deployed service men and women in Operation Iraqi Freedom. METHODS: A cross-sectional study was performed for all dermatology visits presenting to the Combat Dermatology Clinic, Ibn Sina, Iraq, between January 15, 2008 and July 15, 2008. RESULTS: In the six-month period reviewed, 2,696 total patients were evaluated. The most prevalent diagnoses included eczematous dermatitis [17%, n=462] and benign neoplasms [14%, n=375]. Eight percent (n=205) of the total visits were for skin cancer. This included: basal cell carcinoma, squamous cell carcinoma both in-situ and invasive, mycosis fungoides and melanoma. Actinic keratosis comprised 5% of the total visits (n=129). Bacterial infections comprised 6% (n=158) of the total visits and 31 of these cases were community acquired methicillin resistant Staphylococcus aureus (MRSA). LIMITATIONS: Cross-sectional study with referral bias. CONCLUSION: This is the largest publication of the prevalence of skin disease in an exclusively dermatologic clinic in a combat setting. For the first time the presence of skin cancer is noted in a combat setting. The prevalence of MRSA is noted and was exclusively seen in U.S. soldiers. There was a statistically significant rise in the prevalence of eczematous dermatitides when compared with previous conflicts. Dermatologists can have a significant and strategic impact on deployed military medicine.

Subcutaneous nodules with sporotrichoid spread.

BACKGROUND: Mycobacterium marinum is an atypical mycobacterium found worldwide and associated with swimming pools and aquariums. Infections typically present with subcutaneous nodules and lymphangitis. CASE REPORT: A 61-year-old female presented with a two-month history of subcutaneous nodules. The patient had a significant recent history that included rose gardening and cleaning her aquarium at home. Biopsy for histology and tissue culture proved the presence of infection with Mycobacterium marinum and the patient was treated with minocycline. The nodules eventually healed and no new lesions appeared after initiation of treatment. CONCLUSION: Mycobacterium marinum is one of many entities that must be considered in a patient with ascending nodules along the lymphatic drainage of an extremity.

The CASH (color, architecture, symmetry, and homogeneity) algorithm for dermoscopy.

BACKGROUND: The color, architecture, symmetry, and homogeneity (CASH) algorithm for dermoscopy includes a feature not used in prior algorithms, namely, architecture. Architectural order/disorder is derived from current concepts regarding the biology of benign versus malignant melanocytic neoplasms. OBJECTIVE: We sought to evaluate the accuracy of the CASH algorithm. METHODS: A total CASH score (TCS) was calculated for dermoscopic images of 325 melanocytic neoplasms. Sensitivity, specificity, diagnostic accuracy, and receiver operating characteristic curve analyses were performed by comparing the TCS with the histopathologic diagnoses for all lesions. RESULTS: The mean TCS was 12.28 for melanoma, 7.62 for dysplastic nevi, and 5.24 for nondysplastic nevi. These differences were statistically significant (P < .001). A TCS of 8 or more yielded a sensitivity of 98% and specificity of 68% for the diagnosis of melanoma. LIMITATIONS: This is a single-evaluator pilot study. Additional studies are needed to verify the CASH algorithm. CONCLUSIONS: The CASH algorithm can distinguish melanoma from melanocytic nevi with sensitivity and specificity comparable with other algorithms. Further study is warranted to determine its intraobserver and interobserver correlations.

Glomuvenous malformations.

A 9-year-old girl presented with a congenital, blue-purple, partially compressible plaque with a cobblestone surface on the left lateral foot and ankle. Similar, solitary, blue nodules later appeared elsewhere on the extremities. The lesions were tender to palpation and were associated with spontaneous paroxysms of pain and paresthesias. Histopathologic evaluation of a skin biopsy specimen showed rows of glomus cells that surrounded thin-walled vascular channels, which confirmed the diagnosis of glomuvenous malformations. This autosomal dominant condition, which is due to mutations in the GLMN gene, presents with clinical findings that are distinct from those of familial, multiple, cutaneous and mucosal venous malformations. Treatment options include excision, sclerotherapy, and laser therapy (ablative or pulsed dye).

Extramammary Paget's disease of the penis and scrotum.

A 64-year-old Chinese man presented to the Bellevue Hospital Center Department of Dermatology with a 2-year history of an enlarging mass in his suprapubic region, which measured 7 cm x 9 cm and involved the penis and scrotum. A biopsy specimen showed extramammary Paget's disease. Twenty years earlier, while living in China in 1983, this patient had a suprapubic skin cancer which was excised, and he received radiation to the region. Extramammary Paget's disease is a rare cutaneous adenocarcinoma of epidermal origin, which is frequently associated with adnexal carcinoma and internal malignant conditions. Clinically, extramammary Paget's disease is characterized by a red, moist, eroded plaque in the anogenital region. Extramammary Paget's disease usually behaves as a slow-growing intraepithelial adenocarcinoma; however, it may become invasive and may metastasize through dermal lymphatics. The treatment of choice is wide excision.

Juvenile amyopathic dermatomyositis.

A 3-year-old girl presented with a 6-month history of multiple, light-pink, flat-topped papules over the dorsal aspects of the metacarpophalangeal and interphalangeal joints of the hands and feet. Nailfold telangiectases, ragged cuticles, and a heliotrope color of the upper eyelids were also evident, but there was no clinical evidence of muscle weakness and levels of muscle enzymes were normal. A biopsy specimen from one of the papules showed a vacuolar interface dermatitis consistent with a diagnosis of dermatomyositis. This report draws attention to juvenile amyopathic dermatomyositis, which is an uncommon subtype of dermatomyositis with an excellent prognosis.

Allergic contact dermatitis in Operation Iraqi Freedom: use of the T.R.U.E. Test in the combat environment.

BACKGROUND: Refractory dermatitis can frequently cause loss of personnel and poses an economic drain on the military due to the evacuation of civilians and soldiers out of theater. OBJECTIVE: Proof-of-concept retrospective analysis to review the utility of the T.R.U.E. Test in the combat environment. METHODS: Thirty T.R.U.E. Tests were performed by the dermatology clinic in Baghdad, Iraq, between January 15, 2008, and July 15, 2008. Thirty active-duty and civilian contractors referred to the dermatology clinic for dermatitis were tested and four others were clinically rechallenged for suspected bacitracin contact allergy. RESULTS: Of the 30 patients tested, 14 (46.7%) had a positive test reaction to at least one antigen. In these positive tests, nickel, neomycin, and thimersol each comprised 17% followed by neomycin, thimerosal, budesonide, epoxy resin, potassium dichromate, p-phenylenediamine, formaldehyde, quaternium-15, fragrance, and balsam of Peru. All four clinical rechallenges for bacitracin allergy were also positive. CONCLUSIONS: The use of the T.R.U.E. Test in the combat desert environment is an efficient, easy, and clinically relevant method of testing for allergic contact dermatitis. Continued study of the prevalence of allergic contact dermatitis at Ibn Sina Hospital, Baghdad, Iraq, is recommended.