Les dejo 2 casos clínicos de la misma afectación en diferente presentación ¿cuál será? :) Disfruten.
CASO 1
A 20-year-old girl presented with multiple intensely pruritic lesions over left knee of 2-year duration. To start with she had developed a pruritic, erythematous papular lesion over anterio-lateral aspect of left knee just in front of head of fibula. She denied any history of prior injury at the site. Over the next few months new lesions kept appearing over and around the knee which were intensely itchy. Treatment from local practitioners provided no relief. Cutaneous examination showed multiple, erythematous, dry, hyperkeratotic, excoriated and crusted, prurigo nodularis-like lesions in linear and bizarre pattern over and around the left knee. Systemic examination and routine laboratory investigations were essentially normal.
A lesional biopsy was submitted for histology with the clinical diagnosis of nodular prurigo. Histopathology of skin biopsy revealed well formed peri-appendageal epitheloid cell granulomas along with Langhans' giant cells in the papillary and reticular dermis, the features suggestive of lupus vulgaris PAS and Z-N staining was noncontributory.
Mantoux test was negative. No growth was obtained in culture of biopsy specimens on SDA and L-J media. She was put on ATT as in case 2 and asked to return after 4 weeks. However, she did not show any response to this treatment. Empirical treatment with SSKI started in view of endemicity of cutaneous sporotrichosis in the region. There was significant decrease in itching and lesion size within 4 weeks. Complete healing of all lesions with hypertrophic scarring was observed after 12 weeks' treatment. She was advised to continue SSKI for another 4 weeks.
CASO 2
A 25-year-old female was hospitalized with erythematous painful ulcerated swelling over the base of right middle finger of 2 months' duration causing painful and restricted hand movements. Similar lesions had also developed over right wrist, forearm and elbow, right buttock, thigh and left leg during this period. Starting spontaneously as erythematous nodular lesions few of them burst in next 5-7 days discharging sero-sanguineo-purulent material. Historically, she was taking anti-tuberculosis treatment (ATT) comprising rifampicin (450 mg/d), isoniazid (300 mg/d), ethambutol (800 mg/d) and pyrazinamide (1,200 mg/d) for suspected tubercular minimal pleural effusion diagnosed 5 months back. She had also under gone incision and drainage 2 months back for suspected tubercular right knee effusion. On cutaneous examination lesions were multiple, erythematous to violaceous, nodulo-ulcerative swellings.
They were warm to touch, tender and boggy in consistency. Some of them had serosanguineous discharge or crusting, and a puckered scar over right knee. There was no regional lymphadenopathy and other systemic examination was normal. She was investigated with the clinical diagnosis of disseminated tuberculosis. Routine laboratory investigations including pus culture (aerobic and anaerobic), chest X-ray, Mantoux test and HIV serology showed no abnormality. She had no other predisposing factors for immune suppression. Repeated microscopy of pus in potassium hydroxide (KOH) mounts or Z-N staining showed no grains or acid fast bacilli (AFB). X-ray films of right hand showed osteopenia of underlying bones and an osteolytic lesion in proximal phalanx of right middle finger. Biopsy from finger lesion revealed focal epithelial hyperplasia and acanthosis, vacuolar degeneration of basal layer and exocytosis, perivascular mononuclear cell infiltrate in the upper dermis, lymphohistiocytes, neutrophils, plasma cells and epithelioid cell infiltrate in the mid and lower dermis. PAS and Z-N staining was noncontributory. Culture of biopsy specimens on L-J media was negative while growth of S. schenckii was obtained on SDA (identified as in case 1). Healing of all skin lesions was observed after 12 weeks' treatment with SSKI. She did not follow up further.
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CASO 2
A 25-year-old female was hospitalized with erythematous painful ulcerated swelling over the base of right middle finger of 2 months' duration causing painful and restricted hand movements. Similar lesions had also developed over right wrist, forearm and elbow, right buttock, thigh and left leg during this period. Starting spontaneously as erythematous nodular lesions few of them burst in next 5-7 days discharging sero-sanguineo-purulent material. Historically, she was taking anti-tuberculosis treatment (ATT) comprising rifampicin (450 mg/d), isoniazid (300 mg/d), ethambutol (800 mg/d) and pyrazinamide (1,200 mg/d) for suspected tubercular minimal pleural effusion diagnosed 5 months back. She had also under gone incision and drainage 2 months back for suspected tubercular right knee effusion. On cutaneous examination lesions were multiple, erythematous to violaceous, nodulo-ulcerative swellings.
They were warm to touch, tender and boggy in consistency. Some of them had serosanguineous discharge or crusting, and a puckered scar over right knee. There was no regional lymphadenopathy and other systemic examination was normal. She was investigated with the clinical diagnosis of disseminated tuberculosis. Routine laboratory investigations including pus culture (aerobic and anaerobic), chest X-ray, Mantoux test and HIV serology showed no abnormality. She had no other predisposing factors for immune suppression. Repeated microscopy of pus in potassium hydroxide (KOH) mounts or Z-N staining showed no grains or acid fast bacilli (AFB). X-ray films of right hand showed osteopenia of underlying bones and an osteolytic lesion in proximal phalanx of right middle finger. Biopsy from finger lesion revealed focal epithelial hyperplasia and acanthosis, vacuolar degeneration of basal layer and exocytosis, perivascular mononuclear cell infiltrate in the upper dermis, lymphohistiocytes, neutrophils, plasma cells and epithelioid cell infiltrate in the mid and lower dermis. PAS and Z-N staining was noncontributory. Culture of biopsy specimens on L-J media was negative while growth of S. schenckii was obtained on SDA (identified as in case 1). Healing of all skin lesions was observed after 12 weeks' treatment with SSKI. She did not follow up further.
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