Bilateral bartholin's gland abscesses in a 4-year-old girl with vitamin a deficiency: a case report.

BACKGROUND: A Bartholin's gland abscess is one of the most common infections in women of reproductive age. Although Bartholin's gland abscesses have been reported in prepubertal children, they are rarer in prepubertal children than in adults. Herein, we report a case of bilateral Bartholin's gland abscesses in a 4-year-old girl with vitamin A deficiency. CASE PRESENTATION: A 4-year-old girl diagnosed with autism spectrum disorder was admitted to the hospital for close examination and treatment because of persistent fever and malaise. The child was a marked fussy eater and was diagnosed with corneal ulceration and night blindness secondary to vitamin A deficiency. Both of the patient's labia were swollen, and a diagnosis of a bilateral Bartholin's gland abscess was made using computed tomography. Incisional drainage was performed under general anesthesia. The patient's postoperative course was uneventful, and she was discharged from the hospital on day 8 after the surgery. During hospitalization, attempts were made to correct the vitamin deficiency by adding nutritional supplements to the diet. Three months after the surgery, no recurrence of abscesses was noted. CONCLUSIONS: Decreased immunocompetence and mucosal barrier function due to vitamin A deficiency is thought to be the underlying cause of Bartholin's gland abscesses. Although prepubertal Bartholin's gland abscesses have been reported, they are rare. To the best of our knowledge, no reports of bilateral Bartholin's gland abscesses potentially caused by vitamin A deficiency have been reported. When prepubertal girls present with Bartholin's gland abscesses, the presence of immunodeficiency due to vitamin or trace element deficiency should also be considered.

Association of Bartholin cysts and abscesses and sexually transmitted infections.

INTRODUCTION: Bartholin gland cysts or abscesses account for many gynecologic visits in the emergency department (ED). Previous smaller studies have suggested a link between Bartholin cysts/abscesses and sexually transmitted infections (STIs), but few studies have involved the ED. METHODS: We retrospectively identified patients aged 18 years or older seen in 1 ED between January 2012 and March 2017 who had urinalysis and urine culture and/or were tested for gonorrhea, chlamydia, or trichomonas by nucleic acid amplification testing. Univariate and multivariate analyses were used to evaluate associations between Bartholin cysts/abscess and demographics, laboratory findings, and ED diagnoses. RESULTS: Data were collected for 75,000 ED patients; 64 patients had a diagnosis of Bartholin cyst or abscess, 40 of whom were also tested for Neisseria gonorrhoeae or Chlamydia trachomatis. Ten percent of patients with a Bartholin cyst/abscess were infected with N gonorrhoeae, compared with 3% of those without a Bartholin cyst/abscess (P = .008). The rates of C trachomatis and Trichomonas vaginalis infections were 13% and 26%, respectively, among patients with a Bartholin cyst/abscess, compared with 8% and 30%, respectively, among those without a Bartholin cyst/abscess (P > .05 for both). On regression analysis, only increased urobilinogen level (ß, 0.31; odds ratio, 1.36; 95% CI, 1.11-1.66; P = .003) and infection with N gonorrhoeae (ß, 1.69; odds ratio, 5.40; 95% CI, 1.43-20.35; P = .01) were associated with a Bartholin cyst/abscess. CONCLUSIONS: Clinicians in the ED should consider testing patients with a Bartholin cyst/abscess for gonorrhea.

Vulvar Majocchi granuloma and kerion formation in an immunocompetent female.

We report a rare case of vulvar Majocchi granuloma and kerion formation secondary to Trichophyton in an immunocompetent woman. The patient responded well to oral terbinafine and a short course of oral corticosteroids with a slow taper. Resolution of deep dermatophytosis requires prompt pathogen identification and treatment to avoid scarring and hair loss. Herein, we aim to increase clinical awareness and early recognition of this atypical presentation of a Majocchi granuloma with kerion formation.

Ecthyma Gangrenosum: Vulvar Ulcers, Pseudomonas, and Pancytopenia: A Case Report of an 18-Month-Old Female Toddler.

BACKGROUND: An 18-month-old female toddler presented with severe vulvar ulcers and pancytopenia with investigations revealing Pseudomonas aeruginosa bacteremia. CASE: A previously healthy 18-month-old female toddler presented with 6 days of fevers, vulvar rash, and ulcers. Vulvar cultures showed Staphylococcus aureus and P aeruginosa. Bloodwork showed pancytopenia and P aeruginosa bacteremia. She started receiving broad-spectrum antibiotics. Bone marrow aspirate revealed a hypocellular marrow with erythroid dysplasia. Vulvar ulcers progressed rapidly, therefore magnetic resonance imaging was performed to rule out necrotizing fasciitis. She was diagnosed with ecthyma gangrenosum (EG). Three months after initial presentation, she was diagnosed with precursor B-cell acute lymphoblastic leukemia. SUMMARY AND CONCLUSION: This case highlights that health care providers should suspect EG when severe vulvar ulcers are present with P aeruginosa infection and neutropenia. Because EG poses significant morbidity and mortality, its presence should prompt aggressive antimicrobial therapy and mobilization of a multidisciplinary team to initiate workup for an underlying immunodeficiency syndrome or malignancy. This case also illustrates that surgical debridement might be avoided in certain patients with EG as long as meticulous wound care and close monitoring with a multidisciplinary team are in place.

Pseudoepitheliomatous hyperplasia causing a painful plaque in a HIV-infected female.

Dermatological conditions are more common and can present atypically, in human immunodeficiency virus-infected individuals. This case report describes a 22-year-old human immunodeficiency virus-positive Caucasian female who presented with a vulval lesion eight weeks after starting antiretroviral treatment. Clinical examination revealed a 2 cm well-demarcated plaque on the outer aspect of the left labium minus. The lesion was tender, no contact bleeding or ulceration present. She was presumptively treated for chancroid and herpes simplex with 500 mg ceftriaxone IM stat, 1 g azithromycin PO stat, and valacyclovir 500 mg BD for five days. The lesion persisted despite treatment, and during follow-up, a punch biopsy was carried out. She was diagnosed with pseudoepitheliomatous hyperplasia of the epidermis. In addition to highlighting this condition that has been previously reported in human immunodeficiency virus/herpes simplex virus co-infection, this case demonstrates that unusual skin presentations must be considered in human immunodeficiency virus-infected individuals and illustrates the importance of biopsy for any non-healing lesions.

Skin diseases of the vulva: Infectious diseases.

A multitude of infectious diseases of viral (genital herpes, herpes zoster, genital warts and molluscum contagiosum), bacterial (syphilis, chancroid, lymphogranuloma venereum, donovanosis, erysipelas, cellulitis and necrotising fasciitis, folliculitis, impetigo, bartholin gland abscess, trichomycosis and erythrasma), fungal (candidiasis and dermatophytosis) and parasitic (pediculosis pubis) origin may affect the vulvar area. Herein, we review the infections and their skin manifestations in the vulvar area.

The ABCs of Perineal Streptococcal Dermatitis.

Perineal streptococcal dermatitis (PSD) is largely known to be caused by group A ß-hemolytic Streptococcus (GAS). We would like to bring cases of non-GAS PSD to the attention of dermatologists, as there are implications for workup and therapy. We report 3 pediatric cases of PSD: 1 caused by GAS, 1 caused by group B ß-hemolytic Streptococcus (GBS), and 1 associated with group C ß-hemolytic Streptococcus (GCS). GBS and GCS are very rarely reported in pediatric cases of PSD. The literature on non-GAS PSD is reviewed, which additionally revealed several instances of PSD caused by group G ß-hemolytic Streptococcus (GGS) and Staphylococcus aureus. GBS, GCS, GGS, and S aureus are significant causes of PSD to consider, particularly among adult patients, based on our encountered cases and the literature. If using rapid antigen tests to expedite the diagnosis of GAS, we recommend supplementing with a lesional swab for bacterial culture and sensitivity as the rapid antigen test does not detect non-GAS organisms. Therapy should be tailored to the microbiologic cause.

Oral and vulvovaginal changes in pregnancy.

Physiologic alterations of the oral and vulvovaginal mucosal surfaces result from the profound hormonal and immunologic changes of gestation. High estrogen levels are responsible for the vascular changes noted on mucosal surfaces. Gingival hyperemia and edema, gingivitis and pyogenic granuloma are the most common alterations of the oral mucosa during gestation. Physiologic changes of the vulvovaginal area are mainly of vascular nature, and include among others varicose veins. The oral and vulvovaginal mucosal surfaces can be affected by diseases that can worsen or develop in pregnancy. Oral lesions are encountered in a large spectrum of diseases including aphthosis, pemphigus vulgaris, systemic lupus, and Behçet disease. Pregnancy dermatoses such as impetigo herpetiformis and gestational pemphigoid can exceptionally affect the oral mucosa. Infections of the vulvovaginal region by Candida species, Trichomononas vaginalis, human papilloma virus, and herpes simplex virus have been associated with fetal risks. The dermatologist, obstetric medicine physician, and neonatologist should be familiar with the above physiologic changes as well as maternal/fetal risks relevant to disease affecting these mucosal surfaces during gestation.

Kerion of the vulva caused by Trichophyton mentagrophytes.

BACKGROUND: Deep dermatophytosis of genital skin is a rare clinical manifestation of infection by a common group of pathogens. OBJECTIVE: We emphasize the importance of clinical suspicion and the use of accurate diagnostic methods in the evaluation of deep dermatophytosis. METHODS: We report a single case of tinea pubis, kerion type, caused by Trichophyton mentagrophytes in an immunocompetent host. RESULTS: A 54-year-old female presented with a suppurative infection of the vulva and pubis that was unresponsive to empirical antibiotic therapy. T. mentagrophytes was isolated. Oral itraconazole was initiated on the basis of clinical suspicion and continued for a total of 6 weeks. CONCLUSION: Accurate diagnosis and treatment of deep dermatophytosis of genital skin rests upon proper identification of the pathogen. Prompt initiation of treatment with an oral antifungal agent, such as itraconazole, should be undertaken in order to avoid irreversible scarring alopecia.

Complicated rectovaginal fistula secondary to Bartholin's cyst infection.

Rectovaginal fistula formation secondary to Bartholin's cyst is a very rare complication, and to date only three cases were reported in the literature. We report a case of a 32-year-old woman who suffered recurrent episodes of Bartholin's cyst infection with subsequent abscess formation that resulted in rectovaginal fistula formation. We treated her initially with transperineal repair; however, the fistulous tract recurred a month later. A laparoscopic colostomy and transperineal repair using biological graft was then performed, with excellent results. The patient underwent reversal of colostomy after 2 months, and remained asymptomatic upon follow-up 12 months later.

Botryomycosis of the vulva: a case report.

OBJECTIVE: Vulvar ulcers may be caused by various etiologies including infection, trauma, dermatosis, and cancer. We report a case of a vulvar ulcer caused by botryomycosis. CASE: An 85-year-old woman presented with vulvar itching, pain, bleeding, and ulcerations suspicious for cancer. Biopsies of the ulcers returned without dysplasia or malignancy. She was referred to the tertiary care vulvar vaginal disease clinic. Dermatopathologic reevaluation of pathologic slides diagnosed lichen sclerosus and botryomycosis. The patient was treated with ciprofloxacin for 7 weeks with complete resolution of vulvar ulcerations. CONCLUSION: Botryomycosis should be included in the differential diagnosis of infectious etiology of vulvar ulcers.

Vulvar pseudoepitheliomatous hyperplasia associated with herpes simplex virus type II mimicking cancer in an immunocompromised patient.

We report an exaggerated dermatological inflammatory condition in an immunocompromised patient. The patient was a 51-year-old woman who had HIV infection and a history of cervical cancer. Three years after highly active antiretroviral therapy with an improved immune status, and 2 years after remission of cervical cancer, she developed verrucous perineal masses. Provisional diagnosis was recurrent cervical cancer or primary vulvar cancer. Pathological features revealed pseudoepitheliomatous hyperplasia associated with herpes viral infection. After minimal response to systemic oral antiviral drugs and topical imiquimod, she had clinical resolution with the addition of systemic oral corticosteroid.

Vulval disease in HIV-positive women attending a tertiary vulval dermatology clinic over a five-year period.

There is a paucity of data on vulval disease in HIV-infected women. We describe the spectrum of vulval disease in HIV-infected women attending a tertiary vulval dermatology referral centre over a five-year period. Seven vulval conditions were identified in 14 women. Most were attending for HIV care (n = 12, 86%), and on combined antiretroviral therapy (CART) with a CD4 cell count above 200 cells/µL (n = 9, 64%) at diagnosis. Imiquimod therapy was effective in treating undifferentiated vulval intraepithelial neoplasia (uVIN) - the most common diagnosis. There were no cases of invasive vulval carcinoma. Hypertrophic herpes simplex virus occurred in one woman stable on CART with good immune reconstitution. Clinicians should be vigilant about the spectrum of vulval disease in HIV-infected women and consider genital examination as part of routine care.

Vulvar histoplasmosis as a rare cause of genital ulceration.

BACKGROUND: Histoplasmosis is an infection caused by the dimorphic fungus Histoplasma capsulatum and primarily presents with pulmonary symptoms. Immunocompromised individuals are at high risk for contracting disseminated histoplasmosis, which can be fatal if left untreated. CASE: We present a case involving a 50-year-old woman with acquired immunodeficiency syndrome with an ulcerated vulvar lesion concerning for carcinoma. Extensive workup revealed disseminated histoplasmosis without pulmonary manifestations. She was treated with an extended course of an antifungal agent. Her vulvar lesion resolved. CONCLUSION: Vulvar histoplasmosis is a rare etiology of vulvar pathology but one that should be considered in immunocompromised patients.

Paucibacillary tubercular vulval ulcer in a sexually inactive pubertal girl: role of therapeutic trial.

BACKGROUND: Genital ulcers in adolescent girls present a complex diagnostic dilemma. Of all the causes of painful vulval ulcer in a virgin girl, tuberculosis is an extremely rare possibility with no case reported in literature. CASE: We are reporting a case of tubercular vulval ulcer in a sexually inactive pubertal girl. She had a close contact with active tuberculosis, positive tuberculin skin test, and chronic granulomatous inflammation on vulval biopsy. Therapeutic trial was offered and on follow up visit after 4 weeks, lesion had completely resolved. SUMMARY AND CONCLUSION: Unlike previous case reports that describe tubercular vulval ulcers in sexually active or post menopausal women our patient was sexually inactive. In endemic areas tuberculosis should be considered in differential diagnosis of vulval ulcers irrespective of sexual history of the patient.

Hypertrophic donavanosis in a young pregnant woman.

BACKGROUND: Donovanosis is a chronic bacterial illness, progressive and indolent, which normally attacks the skin and mucous membranes in the genital and perigenital regions. CASE: An 18-year-old pregnant female presented with large, hypertrophic lesions in the ano-genital region. HIV serology was negative. Pap smear revealed a CIN 1 associated with HPV infection. Biopsy yielded macrophages laden with Gram-negative Donovan bodies. SUMMARY AND CONCLUSION: A diagnosis of vulvar and perianal donovanosis was reached; the patient decided to terminate the pregnancy and was treated with azithromycin, which led to clinical resolution.

Vulvar pythiosis in two captive camels (Camelus dromedarius).

Two camels (Camelus dromedarius), 3- and 4-years-old, respectively, from an eastern Tennessee wildlife farm presented with persistent weight loss and large vulvar masses. An initial biopsy of the vulvar mass of one of the camels performed by a local veterinarian showed eosinophilic dermatitis. An allergic or parasitic dermatitis was suspected. The two camels were treated with one dose of sodium iodide (66 mg/kg, in 1.0 L of normosolR, IV) and ivermectin 1% (200 ug/kg PO). Upon presentation at the Veterinary Teaching Hospital, University of Tennessee, additional biopsies of the masses again revealed eosinophilic dermatitis. Microscopic examination of a Gomori methenamine silver (GMS)-stained section prepared from the biopsy of one of the camels revealed the presence of fungal-like hyphae of a mold which was suspected to be Pythium insidiosum. The vulvar masses were surgically debulked in both animals and sodium iodide and Pythium-immunotherapy prescribed. Pythium insidiosum was isolated in culture and hyphae elements were detected in histological sections confirming the diagnosis of pythiosis in both animals. Despite signs of progressive healing of the vulvar surgical areas, postoperative persistent weight lost in one of the camels suggested the possibility of gastro intestinal (GI) tract pythiosis. This camel died 5 months after the first onset of clinical signs and unfortunately a necropsy was not performed. The other camel responded well to the combination of surgery, iodides, and immunotherapy and has currently rejoined the other members of the herd.