HIV and skin infections.

HIV infection alters the skin microbiome and predisposes to a wide range of cutaneous infections, from atypical presentations of common skin infections to severe disseminated infections involving the skin that are AIDS-defining illnesses. Bacterial infection of the skin, most commonly caused by Staphylococcus aureus, occurs frequently and can result in bacteremia. Nontuberculous mycobacterial infections that are usually localized to the skin may disseminate, and guidance on the treatment of these infections is limited. Herpes simplex can be severe, and less common presentations such as herpetic sycosis and herpes vegetans have been reported. Severe herpes zoster, including disseminated infection, requires intravenous antiviral treatment. Viral warts can be particularly difficult to treat, and in atypical or treatment-resistant cases a biopsy should be considered. Superficial candidosis occurs very commonly in people living with HIV, and antifungal resistance is an increasing problem in non-albicans Candida species. Systemic infections carry a poor prognosis. In tropical settings the endemic mycoses including histoplasmosis are a problem for people living with HIV, and opportunistic infections can affect those with advanced HIV in all parts of the world. Most cutaneous infections can develop or worsen as a result of immune reconstitution in the weeks to months after starting antiretroviral therapy. Direct microscopic examination of clinical material can facilitate rapid diagnosis and treatment initiation, although culture is important to provide microbiological confirmation and guide treatment.

[Distribution of dermatoses encountered in children seen in Dermatological Consultations in Lomé (Togo)]. / Distribution des dermatoses rencontrées chez les enfants vus en Consultation Dermatologique à Lomé (Togo).

Objective: The aim of this study was to establish the overview of current dermatosis in children in dermatological consultation in Lomé and to deduce the evolutionary trend of these dermatoses between 1992 and 2020. Method: This was a retrospective descriptive study concerning patients aged 0 to 15 years seen in consultation in the public dermatological services of Lomé from January 1, 2010 to December 31, 2019. The reasons for consultation were reviewed and classified into groups of dermatosis (immunoallergic, infectious, inflammatory, tumoral …). The results of this series were compared with those of a similar study carried out in 1992. Results: During the study period, 3 767 children attended showing dermatological condition (14.2% of the dermatological consultations were pediatric). The average age of the patients was 7.4 years and the sex ratio M/F was 0.7. July, August and September were the months with the highest number of consultations. The top three reasons for consultation were eczema (26.6%), prurigo strophulus (15.3%) and atopic dermatitis (4.9%). 51.3% of skin diseases in children were represented by immunoallergic dermatoses, followed by infectious dermatoses 23.6%. The predominant infectious dermatoses were fungal (34.4%) and bacterial (30.3%). Between 1992 and 2019, there was an increase in the prevalence of immunoallergic dermatoses and a reduction in infectious dermatoses. Conclusion: Immunoallergic dermatoses are predominant and clearly increasing among children seen in dermatological consultations in Lomé.

Protothecosis in the mucosa of the pharynx mimicking pharyngeal cancer in an immunocompetent individual: a case report.

BACKGROUND: Protothecosis is a rare infection in humans and animals caused by the achlorophyllic algae Prototheca species. More than half of the protothecosis cases are cutaneous infections, and most cases are observed in immunocompromised individuals. CASE PRESENTATION: We report a case of Prototheca wickerhamii infection in the mucosa of the pharynx in a 53-year-old immunocompetent woman with an incidentally found mass lesion at the left tongue base. Histopathological findings of the mass lesion suggested cryptococcosis, but P. wickerhamii was identified from the oropharynx scrape culture based on DNA sequencing. After surgical resection, fosfluconazole treatment was initiated, and subsequently, treatment was switched to topical amphotericin B. The residual mass lesion did not deteriorate during the 4-month antifungal treatment and 1-year observational period. CONCLUSIONS: Prototheca species can be easily misdiagnosed as yeasts because of their morphological and pathological similarities. Prototheca, in addition to Cryptococcus should be considered if slow-growing, large Gram-positive organisms are encountered. Lactophenol cotton blue staining of the colony helps distinguish these organisms. Further study is needed to determine the appropriate treatment according to the infection focus.

[Soft tissue infections]. / Weichgewebeinfektionen.

Acute skin and soft tissue infections are among the most frequent infections in medicine. There is a broad spectrum including simple local infections as well as severe and life-threatening diseases. Along with Staphylococcus aureus, group A Streptococci are mainly responsible for these illnesses. The therapeutic approach ranges from antiseptic local treatments to administering systemic antibiotics or emergency surgery. Treating physicians often face challenges when presented with soft tissue infections due to a great discrepancy between the first impression of the disease compared to a possibly quick progression as well as the wide range of sometimes confusing historic terms and definitions being used in the English and German language, for instance pyoderma, erysipelas or phlegmon. A recently more popular collective term emphasized by clinical trials is "acute bacterial skin and skin structure infections" (ABSSSI).

Case for diagnosis. Ulcer and papular lesions in a patient with diabetes mellitus. protothecosis

Abstract Protothecosis is a rare disease caused by achlorophilic algae of the genus Prototheca spp. In general, three clinical forms are observed: cutaneous, articular and systemic. The cutaneous form is the most common one. This study describes a patient with isolated erythematous papules and erythematous papular plaques in the scapular regions, with a previous histopathological diagnosis of cryptococcosis. New tests were conclusive for the diagnosis of protothecosis, caused by Prototheca wickerhamii.

Acroangiodermatitis of the hand secondary to a dysfunctional arteriovenous fistula.

Acroangiodermatitis (AAD) is often seen in association with various vascular anomalies such as venous insufficiency, vascular syndromes, and conditions associated with thrombosis. This is the first case reported in the literature associated with arteriovenous fistula stenosis in a patient with chronic kidney disease on hemodialysis. This case is being described for its rarity and to familiarize the clinicians with this unusual complication, especially, to prevent them from thinking of this condition as an infectious complication. It is essential to recognize the uniqueness of the pathophysiology of this disease and to do a clear distinction with that of a venous ulcer. With this work we also aim to help health practitioners with proper management of the condition. As we've seen, surgical treatment in appropriately selected cases corrects the reflux of the venous system and successfully improves the appearance of the verrucous lesion. Our patient was successfully treated by correcting the arteriovenous fistula stenosis with near-complete subsidence of the verrucous lesion within days of the procedure. Acroangiodermatitis management must be conducted with a multidisciplinary approach (dermatology, vascular surgery, and internal medicine). It is essential the comprehensive management of these patients, to ensure prompt recovery and avoid chronic effects, as well as to guarantee the quality of life in the future.

Enfrentamiento de las infecciones de piel en el adulto / Managing adult skin infections

En la actualidad, las infecciones de piel y partes blandas forman parte de un alto porcentaje de las consultas en salud. Estas van desde infecciones leves, donde el manejo se realiza con tratamiento tópico, hasta aquellas con severo compromiso sistémico, requiriendo terapia antibiótica sistémica e incluso el desbridaje quirúrgico. En general, son producto de un desbalance entre los mecanismos de defensa de la barrera cutánea y los factores de virulencia y patogenicidad de los microorganismos que la afectan. Se pueden clasificar según distintos criterios, como por ejemplo, profundidad, gravedad, microorganismos involucrados y si estas son purulentas o no. El reconocer estas entidades clínicas es de suma importancia para llevar a cabo un adecuado tratamiento en los pacientes que presentan estas afecciones, ya que los diagnósticos erróneos llevan a las múltiples consultas con el consiguiente aumento de costos asociados en atención en salud.

Currently, skin and soft tissue infections are part of a high percentage of health consultations. These range from mild infections, where management is performed with topical treatment, to those with severe systemic compromise requiring systemic antibiotic therapy and even surgical debridement. In general, they are the product of an imbalance between the defense mechanisms of the skin barrier and the virulence and pathogenicity factors of the microorganisms that affect it, which can vary from bacterial, viral, fungal and parasites agents. Skin and soft tissue infections can be classified according to different criteria, such as depth, severity, microorganisms involved and whether they are purulent or not. Recognizing these clinical entities is of utmost importance to carry out adequate treatment in patients with these conditions, since erroneous diagnoses lead to multiple consultations with the consequent increase in costs associated with health care

[Cutaneous complications following hematopoietic stem cell transplantation]. / Complications cutanées post-allogreffe de cellules souches hématopoïétiques.

BACKGROUND: Hematopoietic stem cell allograft is a treatment for patients with severe constitutional or acquired hematopoietic system diseases. This act is always linked to complications requiring multidisciplinary care. Our study describes the post-allograft cutaneous complications. METHODS: A prospective study was conducted at the Hematology department of "20 Août Hospital" in Casablanca during a period going from January 2018 to December 2020; including all patients who presented acute or chronic cutaneous complications post-allograft. RESULTS: Twenty-five patients were included. All patients received induction chemotherapy (Busulfan/Fludarabine or Busulfan/Melphalan). A skin infection was found in 8 patients : four cases of Malassezia folliculitis, one case of perineal zona, one case of genital herpes, one case of varicella and one case of Candida sepsis. The acute graft versus host reaction was found in 3 patients, revealed by an erythematous rash all over the body. The chronic graft versus host reaction was found in five patients on a lichenoid form. Nine patients had a hyperpigmentation of the folds followed by detachment in the same areas, concluding to a Busulfan toxidermy. DISCUSSION: Hematopoietic stem cell allograft has many complications. The literature mainly specifies hematological and digestive complications, while skin complications are little described. Our series is special by reporting different types and mechanisms of skin complications that can occur; with a predominance of skin graft-on-host reactions and infections. It also reports an unusual Busulfan toxidermy.

Effective Treatment of Cutaneous Mold Infections by Antimicrobial Blue Light That Is Potentiated by Quinine.

BACKGROUND: Cutaneous mold infections commonly result from an array of traumatic injuries that involve direct inoculation of contaminated soil into wounds. Here, we explored the use of antimicrobial blue light (aBL; 405 nm wavelength) and the combination of aBL with quinine hydrochloride (aBL + Q-HCL) for the treatment of cutaneous mold infections. METHODS: Efficacy of aBL and aBL + Q-HCL in killing clinically important pathogenic molds (Aspergillus fumigatus, Aspergillus flavus, and Fusarium oxyprorum) was investigated. Ultraperformance liquid chromatography identified and quantified endogenous porphyrins in the mold conidia. Finally, a mouse model of dermabrasion wound infected with a bioluminescent variant of A. fumigatus was developed to investigate the efficacy of aBL in treating cutaneous mold infections. RESULTS: We demonstrated that mold conidia are tolerant to aBL, but Q-HCL enhances efficacy. Transmission electron microscopy revealed intracellular damage by aBL. aBL + Q-HCL resulted in intracellular and cell wall damage. Porphyrins were observed in all mold strains, with A. fumigatus having the highest concentration. aBL and aBL + Q-HCL effectively reduced the burden of A. fumigatus within an established dermabrasion infection and limited recurrence posttreatment. CONCLUSIONS: aBL and aBL + Q-HCL may offer a novel approach for the treatment of mold infections.

Diagnostic Utility of Biplex/Multiplex Polymerase Chain Reaction in Infectious Granulomatous Dermatitis in North Indian Population.

BACKGROUND: A definite diagnosis of infectious granulomatous dermatitis (IGD) is difficult for both practicing dermatologists and dermatopathologists due to overlapping clinical and histomorphological features. We aimed to explore the role of multiplex polymerase chain reaction (PCR) for identifying a definite etiological agent for diagnosis and appropriate treatment in IGD in formalin-fixed paraffin-embedded tissue. MATERIALS AND METHODS: Sixty-two cases of IGD were included, excluding leprosy. The histochemical stains including Ziehl-Neelsen, periodic acid-Schiff, and Giemsa were performed in all cases. A multiplex PCR was designed for detection of tuberculosis (TB) (IS6110 and mpt64), fungal infections (ITS1, ITS2; ZM1, and ZM3), and leishmaniasis (kDNA). The results of histomorphology, histochemical stains, and multiplex PCR were compared. RESULTS: Among 62 cases, the sensitivity rate of PCR detection for organisms was 16.7%, 0%, 100%, 72%, 75%, and 66.7% in patients with TB, suggestive of TB, leishmaniasis, fungal infections, and granulomatous dermatitis not otherwise specified and granulomatous dermatitis suggestive of fungus, respectively. The TB PCR using IS6110 primers was negative in all cases; however, PCR using mpt64 primers was positive in 33.33% cases of scrofuloderma. The histochemical stains including Ziehl-Neelsen for acid-fast bacilli, periodic acid-Schiff for fungus, and Giemsa for Leishman-Donovan bodies showed positivity in 11.3%, 43.5%, and 3.2%, respectively. CONCLUSION: A multiplex PCR (Mycobacterium tuberculosis, Leishmania, and panfungal) is highly recommended in all cases of IGD where an etiological agent is difficult to establish by skin biopsy and histochemical stains along with a clinicopathological correlation. This will augment in appropriate treatment and will reduce empirical treatment and morbidity in such patients.

Protothecosis and chlorellosis in sheep and goats: a review.

Protothecosis and chlorellosis are sporadic algal diseases that can affect small ruminants. In goats, protothecosis is primarily associated with lesions in the nose and should be included in the differential diagnosis of causes of rhinitis. In sheep, chlorellosis causes typical green granulomatous lesions in various organs. Outbreaks of chlorellosis have been reported in sheep consuming stagnant water, grass from sewage-contaminated areas, and pastures watered by irrigation canals or by effluents from poultry-processing plants. Prototheca and Chlorella are widespread in the environment, and environmental and climatic changes promoted by anthropogenic activities may have increased the frequency of diseases produced by them. The diagnosis of these diseases must be based on gross, microscopic, and ultrastructural lesions, coupled with detection of the agent by immunohistochemical-, molecular-, and/or culture-based methods.

Patterns of Skin Disease in the Context of a High Prevalence HIV Population in Botswana.

The authors reviewed outpatients in a tertiary dermatology clinic in Botswana to expand knowledge on patterns of skin disease in this population with a high prevalence of human immunodeficiency virus (HIV). Approximately one-third of new and follow-up patients were HIV positive. Common dermatologic conditions included eczematous eruptions, viral and fungal infections, malignant neoplasms, vascular disorders, disorders of pigmentation, and mechanical/physical injury-related disorders. HIV has impacted patterns of dermatologic disease in Botswana, with Kaposi sarcoma being the most frequently biopsied condition. Given the shortage of dermatology specialists, resources should be allocated toward education and management of these most prevalent skin conditions.

Refractory Human Cutaneous Protothecosis.

A 67-year-old Scottish woman presented to her general practitioner with a subcentimeter lump between her shoulder blades. The lump was suspected to be an epidermal cyst and was excised. The patient had a history of controlled diabetes. Most summers, she spent a month near a beach resort in Mexico. The lump reappeared after 6 months within the scar area and was re- excised. Both skin excisions were performed in the primary care setting without histologic assessment.

[Disseminated protothecosis with ulcerative granulomatous colitis in a Rhodesian Ridgeback from Germany]. / Ulzerative granulomatöse Kolitis durch Prototheca spp. bei einem Rhodesian Ridgeback in Deutschland.

A 10-month-old male Rhodesian Ridgeback was presented to the Clinic of Small Animal Medicine, LMU, Germany, with a 6-month history of chronic diarrhea and hematochezia. The dog lived in Germany and had never traveled abroad. Complete blood count and serum biochemistry performed by the referring veterinarian revealed neutrophilia, hyperkalemia, and hyponatremia, with a basal cortisol of 4.3 µg/dl, which excluded hypoadrenocorticism. Since antibiotic treatment had not resulted in any improvement, a 2 week course of prednisolone administration had been initiated, leading to a marked deterioration of intestinal signs and a significant weight loss of 6 kg. At the time of referral, the patient was markedly emaciated, dehydrated, hypovolemic and had a rectal temperature of 39.6 °C. Abdominal ultrasound showed a thickened and irregular colonic wall. On colonoscopy, an irregular colonic mucosa with ulcerations was observed. Histopathologic examination revealed an ulcerative granulomatous colitis, and on Periodic acid-Schiff reaction (PAS) numerous organisms consistent with Prototheca spp. were identified. Prototheca zopfii infection was confirmed by culture and MALDI-TOF MS. In order to test for an underlying immunodeficiency, immunoglobulin levels in serum were determined. IgM was decreased, while IgG and IgA levels were within the reference interval. Due to deterioration of general condition, grave prognosis and costs of a treatment trial, the patient was euthanized one week later, and necropsy was performed. Prototheca spp. were detected on histopathologic examination in the lymphnodes, however not in the eyes or the central nervous system. Protothecosis should be considered an differential diagnosis in dogs with chronic diarrhea and ulcerative granulomatous colitis even in dogs living in Germany. Histopathologic examination of colonic biopsies with special stains such as PAS is recommended in every dog with signs of chronic large bowel disease in order to avoid missing this rare infectious disease.

A practical review of dermoscopy for pediatric dermatology part II: Vascular tumors, infections, and inflammatory dermatoses.

In addition to the evaluation of melanocytic growths (Part I), dermoscopy is helpful in the identification and management of vascular tumors, skin infections, and inflammatory conditions. In this practical review, we present the classic dermoscopic findings of the following: vascular tumors, infectious conditions (molluscum contagiosum, scabies, verruca vulgaris), inflammatory conditions (psoriasis, atopic dermatitis), juvenile xanthogranuloma, and nevus sebaceus.

[A chronic wound from Vietnam]. / Eine chronische Wunde aus Vietnam.

Chronic skin lesions that occur in patients who have previously stayed in tropical countries pose a diagnostic challenge for physicians. In particular, if there is a granulomatous inflammatory reaction histologically, infectious diseases should also be included in the differential diagnosis. Particularly in persons returning from high-risk regions such as Vietnam, this includes cutaneous tuberculosis, which entails a thorough examination of the patient and comprehensive therapy. This case study shows which steps should be considered if cutaneous tuberculosis is suspected.

[Inflammoscopy: dermatoscopy for inflammatory, infiltrating and infectious dermatoses : Indication and standardization of dermatoscopic terminology]. / Inflammoskopie: Dermatoskopie bei entzündlichen, infiltrierenden und infektiösen Dermatosen : Indikation und standardisierte dermatoskopische Terminologie.

Dermatoscopy as a noninvasive diagnostic tool is not only useful in the differentiation of malignant and benign skin tumors, but is also effective in the diagnosis of inflammatory, infiltrative and infectious dermatoses. As a result, the need for diagnostic punch biopsies in dermatoses could be reduced. Hereby the selection of affected skin areas is essential. The diagnostic accuracy is independent of the skin type. Helpful dermatoscopic features include vessels morphology and distribution, scales colors and distribution, follicular findings, further structures such as colors and morphology as well as specific clues. The dermatoscopic diagnosis is made based on the descriptive approach in clinical routine, teaching and research. In all clinical and dermatoscopic diagnoses that remain unclear, a punch biopsy with histopathology should be performed. The dermatoscope should be cleaned after every examination according to the guidelines.

[Rubor, calor, dolor, tumor†: skin and soft tissue infections]. / Rubor, calor, dolor, tumor†: infections de la peau et des tissus mous.

Skin infections are a frequent cause of consultation, yet the diagnosis can be challenging for physicians. Microbiological documentation is rare, and empiric antibiotic regimens should cover the most commonly identified bacteria, i.e. streptococci Staphylococcus aureus. Other pathogens should be considered in case of immunosuppression or certain exposures. Necrotizing fasciitis (NF) is a severe but rare infection. Early surgical management in parallel with antibiotics is the cornerstone of treatment. Despite the high incidence of these infections, little progress has been made in their management and some areas of uncertainty exist, especially regarding the optimal duration of treatment, the prevention of recurrences and the use of polyclonal immunoglobulins for NF. This article reviews the main aspects of diagnosis and treatment of these infections.

Les infections de la peau sont fréquentes mais leur diagnostic peut représenter un défi pour le clinicien. La documentation de l'étiologie microbiologique est rare et le traitement empirique doit couvrir les germes fréquents, notamment Streptococcus spp. et Staphylococcus aureus. Des bactéries inhabituelles peuvent être retrouvées lors d'immunosuppression ou exposition spéciale. La fasciite nécrosante (FN) est une infection sévère mais rare, dont le traitement repose sur la chirurgie rapide et l'antibiothérapie. Malgré leur fréquence, peu de progrès ont été réalisés dans la prise en charge de ces infections et des incertitudes persistent par rapport à la durée optimale de traitement, la prophylaxie pour les récurrences ou l'utilité des immunoglobulines polyclonales intraveineuses pour la FN. Cet article aborde les aspects diagnostiques et thérapeutiques de ces infections.

[New aspects in the histopathology of infectious skin diseases]. / Neue Aspekte zur Histopathologie bei Hautinfektionen.

BACKGROUND: An infectious pathogenesis should always be considered in inflammatory infiltrates in the skin. While some organisms can be recognized on hematoxylin-eosin staining (e.g. yeasts, leishmania), histochemical and immunohistochemical stainings are available for others. OBJECTIVES: If no organisms are seen in a section, the diagnosis of an infection cannot be made with surety, but the pattern of the inflammatory infiltrate can still be suggestive of an infectious process. New or little-known reaction patterns and difficulties in differential diagnosis will be demonstrated. MATERIALS AND METHODS: Selective literature review and analysis of individual cases. RESULTS: Studies using molecular techniques to identify organisms in biopsy specimens have helped to better characterize the histomorphological spectrum of skin infiltrates in infectious skin diseases. Apart from unusual herpes simplex and varicella zoster infections, the histopathology of coxsackie virus and measles exanthem, borreliosis, syphilis, and of cutaneous leishmaniasis is demonstrated. For numerous organisms, molecular tests have been established that can be used on the formalin-fixed, paraffin-embedded material. CONCLUSIONS: Selected skin infections demonstrate the broad histomorphological spectrum of skin infiltrates induced by infectious organisms. It is important for histopathologists to know which reaction pattern requires them to alert the clinician to necessary ancillary diagnostics (culture, serology) and when to consider molecular diagnostics to be performed on the biopsy specimen.

Comparison between organismal staining on histology and tissue culture in the diagnosis of cutaneous infection: A retrospective study.

BACKGROUND: In instances of suspected cutaneous infection, the standard of care includes obtaining skin biopsy specimens for histology and tissue culture. Few studies have compared the clinical utility of each test. OBJECTIVE: To assess the concordance of results between tissue culture and histology, as well as the clinicopathologic features that may influence the diagnostic yield of each test. METHODS: A retrospective review of all patients who underwent skin biopsy for histology and tissue culture at New York University from 2013 through 2018. RESULTS: Of 179 patients, 10% had positive concordance, 21% had positive tissue culture only, and 7% had positive histology only. We calculated a kappa correlation coefficient of 0.25 between histology and tissue culture (reference, 0.21-0.39 indicates minimal agreement). Histology exhibited higher sensitivity in detecting fungi, whereas tissue culture was more sensitive in identifying Gram-negative bacteria. Antimicrobial use before biopsy led to significantly fewer positive cultures (37.5% vs 71%; P = .023) in patients ultimately diagnosed with infection. LIMITATIONS: This study was conducted at a single institution, thereby restricting its broad applicability. The lack of a validated criterion standard to diagnose infection also limits interpretation of the results. CONCLUSION: Tissue culture and histopathology often yield discordant results. Dermatologists should recognize specific limitations, yet high clinical utility in special circumstances, of tests when approaching cases of suspected infection.