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.

Clinico-mycological study of dermatophytic infections and their sensitivity to antifungal drugs in a tertiary care center.

BACKGROUND: Worldwide, dermatophytic infections are running a chronic course either due to ineffective treatment or emerging drug resistance. In the past three decades, there has been an increase in incidence and non-responsiveness to conventional antifungals, which suggests that there is a need of antifungal sensitivity testing. AIMS: This study was aimed at identifying clinico-mycological pattern of dermatophytic infections in patients attending thedermatology outpatient department of a tertiary care hospital, and to obtain the sensitivity pattern of isolates against six commonly used oral antifungals (fluconazole, terbinafine, itraconazole, ketoconazole, griseofulvin and voriconazole). METHODS: Patients with suspected dermatophytoses attending the outpatient department of Sir Sunderlal Hospital, Varanasi, were enrolled in the study. A detailed history, clinical examination and sample collection for mycological examinations was done. In vitro antifungal sensitivity testing was done on species isolated from culture as per the Clinical and Laboratory Standard Institute M38-A standards, with broth microdilution method. RESULTS: There were 256 patients recruited in the study, with a male: female ratio of 3:1. The most commonly affected age group was 20-40 years (52.4%). Tinea corporis et cruris was the most common type observed (27.2%). Potassium hydroxide positivity was seen in 211 samples (79.6%) and culture positivity was found in 139 samples (52.4%). The most common species identified was Trichophyton mentagrophytes (75.9%). Sensitivity testing was done on fifty isolates of T. mentagrophytes. Minimum inhibitory concentrations of itraconazole, ketoconazole, terbinafine and voriconazole were comparable, while griseofulvin showed the highest minimum inhibitory concentration. Itraconazole was found to be the most effective drug, followed by ketoconazole, terbinafine and fluconazole. Griseofulvin was the least effective drug among the tested antifungals. LIMITATIONS: This is a hospital-based study, and may not reflect the true pattern in the community. Sensitivity pattern of only one species T. mentagrophytes was carried out. CONCLUSION: Inadequate and irregular use of antifungal drugs has led to the emergence of resistant strains, which cause poor treatment outcomes. Thus, it is very important to test for antifungal sensitivity to check for resistance to antifungals.

Disseminated cutaneous phaeohyphomycosis due to Cladophialophora bantiana.

Cladophialophora bantiana is a neurotropic dematiaceous fungus which only rarely affects the skin. We report a case of disseminated cutaneous phaeohyphomycosis caused by Cladophialophora bantiana in an immunocompromised female who presented with multiple pyogenic granuloma-like nodules, dermatophytosis-like plaque, and subcutaneous cysts on the upper and lower extremities without systemic involvement. Biopsy revealed black yeasts resembling sclerotic bodies and culture yielded irregular, velvety, grey colonies with black reverse. Excision of the nodules and treatment with oral itraconazole 100 mg twice daily resulted in complete clinical resolution within two months, following which itraconazole was administered for another 4 months.

Cutaneous mucormycosis of scalp and eyelids in a child with type I diabetes mellitus.

Scalp mucormycosis in children is extremely rare. We present a case of pediatric scalp mucormycosis caused by Rhizopus oryzae in a 9-year-old diabetic girl who was successfully diagnosed and treated with amphotericin B deoxycholate and wound debridement. At 3 months follow up, the patient was stable although she had lost her vision.

Red face and fungi infection.

Red face syndrome is characterized by an erythematous dermatitis that is produced by different entities. These include rosacea, seborrheic dermatitis, contact dermatitis, atopic dermatitis, psoriasis, cutaneous lupus, photodermatosis, post-topical steroid dermatosis, demodicosis, borderline borderline (BB) leprosy, mastocytosis, carcinoid, postneoplasia flushing, cutaneous lymphoma, tineas, ulerythema ophryogenes, and psychosomatic flushing. Red face is a relatively common dermatologic manifestation. Our goal is to review tinea corporis and other fungi that affect this region causing facial erythema and its therapeutic management.

Primary cutaneous aspergillosis due to Aspergillus tamarii in an immunocompetent host.

Primary cutaneous aspergillosis is a rare disease usually caused by Aspergillus fumigatus, Aspergillus flavus, Aspergillus terreus and Aspergillus ustus. It is usually seen in immunocompromised hosts, though some cases are also reported in immunocompetent hosts. We present a case of an immunocompetent farmer who presented with generalised nodules and plaques, mimicking erythema nodosum leprosum but turned out to be cutaneous aspergillosis caused by Aspergillus tamarii. The characteristic ascospores of Aspergillus species were found in skin lesions on fungus isolated in culture. The patient showed excellent response to antifungal therapy.

Tender cutaneous nodules of the legs: diagnosis and clinical clues to diagnosis.

BACKGROUND: "Tender cutaneous nodules of the legs" is a common manifestation in dermatology. Histopathological investigation is usually required for this condition, because clinical data are frequently insufficient to make a definite diagnosis. OBJECTIVE: To identify and analyze the causes of patients presenting with tender leg nodules and to reveal clinical clues that could help to differentiate causes. MATERIALS AND METHODS: The medical records and histopathological slides of patients presenting with tender cutaneous nodules of the legs between January 2005 and December 2007 were retrospectively reviewed. RESULTS: Of the total of 154 patients, 122 (79.2%) were female. Definite diagnoses were categorized into four groups: inflammation (84.4%); infection (5.8%); tumor (6.5%); and nonspecific (3.2%). The most common cause in the inflammation group was erythema nodosum. The infections found were Acremonium spp., Penicillium sp., Mycobacterium abscessus, Mycobacterium fortuitum and Mycobacterium leprae. The tumors included leiomyoma, leukemia cutis, and lymphomas. Clinical data that correlated with and could be used as clues for the inflammation group were female sex (P = 0.03, OR 6.43) and lower leg involvement (P = 0.03, OR 7.14). LIMITATIONS: The retrospective manner of this study is a limitation. CONCLUSION: Various inflammatory conditions, infections, and tumors can present as tender cutaneous nodules of the legs. Female sex and lower leg involvement were clinical data that could be used as clues for the diagnoses in the inflammation group. However, histopathological investigation is still crucial to determine a definite diagnosis in patients presenting with tender cutaneous nodules of the legs.

Polymerase chain reaction-based molecular diagnosis of cutaneous infections in dermatopathology.

Conventional methods, including microscopy, culture, and serologic studies, are a mainstay in the diagnosis of cutaneous infection. However, owing to limitations associated with these techniques, such as low sensitivity for standard microscopy and in the case of culture delay in diagnosis, polymerase chain-reaction based molecular techniques have taken on an expanding role in the diagnosis of infectious processes in dermatopathology. In particular, these assays are a useful adjunct in the diagnosis of cutaneous tuberculosis, atypical mycobacterial infection, leprosy, Lyme disease, syphilis, rickettsioses, leishmaniasis, and some fungal and viral infections. Already in the case of tuberculosis and atypical mycobacterial infection, standardized polymerase chain-reaction assays are commonly used for diagnostic purposes. With time, additional molecular-based techniques will decrease in cost and gain increased standardization, thus delivering rapid diagnostic confirmation for many difficult-to-diagnose cutaneous infections from standard formalin-fixed paraffin-embedded tissue specimens.

[Leprosy-like cutaneous presentation of Histoplasma capsulatum infection in an African HIV+ patient]. / Istoplasmosi a presentazione cutanea simil-lepromatosa in un paziente africano HIV+.

Histoplasma capsulatum is an opportunistic dimorphic fungus responsible for most often self-limiting or flu-like infections but potentially lethal in immunocompromised hosts. Histoplasmosis is rare in Europe. We reported a case of disseminated histoplasmosis in an African HIV patient with a leprosy-like primary cutaneous presentation and involvement of lungs, brain, limphnodes and eye. The therapy with liposomial B amphotericin and itraconazole led to a prompt resolution of the symptoms.