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Sir, Majocchi granuloma (MG), also known as trichophytic granuloma, deep tinea or nodular granulomatous perifolliculitis, is a chronic, granulomatous folliculitis usually located into the dermis, a...

Background Blastomycosis is a subacute or chronic deep mycosis caused by a dimorphic fungus called Blastomyces dermatitidis , which generally produces a pulmonary form of the disease and, to a lesser extent, extra-pulmonary forms such as cutaneous, osteoarticular and genitourinary, among others. Cutaneous blastomycosis is the second clinical presentation in frequency. It is considered as primary when it begins by inoculation of the fungus due to traumas, and secondary when the lung fails to contain the infection. Case-report We present the case of a 57 year-old male who had a 5 year-history of an irregularly shaped verrucous infiltrative plaque related to and insect bite and posterior trauma due to the manipulation of the lesion. B. dermatitidis was identified using direct examination, stains, isolation in culture media, histopathology, and molecular studies. An antifungal susceptibility test was performed using method M38-A2 (CLSI). Clinical and mycological cure was achieved with itraconazole. Conclusions This cutaneous blastomycosis case acquired in the United States (Indianapolis) is rather interesting and looks quite similar to other mycoses such as coccidioidomycosis or sporotrichosis. The presented case shows one of the multiple issues concerning migration between neighboring countries.

Actinic prurigo (AP) is a chronic idiopathic photodermatosis that primarily affects American Indians in the United States and Mestizos in Latin American countries. Clinically, the onset of the disease is usually in the first decade of life but may appear initially in adult life, and it is characterized by symmetric involvement of sun-exposed areas of the skin, particularly areas of the face, resulting in polymorphic erythematous papules, macules, and plaques in different stages of evolution. Lower lip involvement includes swelling, scaling, fissures, hyperpigmentation, and ulcerations of the vermilion border. and in some cases could represent the only manifestation of the disease. The histopathologic features of AP have been studied; however, there is a controversy regarding whether AP cheilitis has distinct histopathologic features that could allow accurate separation from other specific and nonspecific forms of cheilitis. The diagnosis can be challenging, mainly when lip lesions are the only manifestation of the disease. In this study, the authors investigate the clinicopathologic features of 75 cases of AP cheilitis to provide further criteria for its diagnosis and classification. All 75 patients presented with lip lesions. Thirty-three cases were diagnosed as AP cheilitis with cutaneous lesions and 42 cases were diagnosed as AP cheilitis without cutaneous lesions (only lip lesions). Histologically, of the 33 cases with AP cheilitis with cutaneous lesions, 17 (52%) cases showed follicular cheilitis, and of the 42 cases that had only lip lesions, 18 (43%) cases showed follicular cheilitis. Histologically, AP cheilitis can present as follicular cheilitis; thus, supporting the diagnosis. Also, our findings confirm that lip lesions can present as the only manifestation of the disease, showing typical histological and clinical features. This form of cheilitis has not being well described in the dermatologic and dermatopathologic literature.

Introduction: The present study aimed to establish the frequency and clinical characteristics of cutaneous tuberculosis among Mexican adult patients. Methodology: Ninety-five patients with clinically compatible lesions to cutaneous tuberculosis participated in the study. All patients were HIV negative and none of them had previous anti-TB treatment. A skin biopsy was taken from every patient suspected of having tuberculosis, and a histopathologic examination was performed as follows: Ziehl-Neelsen staining; culturing of mycobacteria by Löwenstein-Jensen (L-J) medium; Mycobacteria Growth Indicator Tube detection via BACTEC (MGIT-360); and polymerase chain reaction (PCR) with the sequence of insertion IS6110 for Mycobacterium tuberculosis complex. Results: Tuberculosis was confirmed in 65 out of 95cases (68.4%). Identified lesions were scrofuloderma (42 cases, 64.6%); lupus vulgaris (12 cases, 18.4%); warty tuberculosis (six cases, 9.2%); and papulonecrotic tuberculoid (five cases; 7.7%). The Ziehl-Neelsen staining was positive for acid fast bacilli in nine cases (13.8%) and 48 patients were positive for the PCR amplification (73.8%). All skin biopsies resulted positive for tuberculosis. A positive clinical response to the specific treatment was considered a confirmation for tuberculosis. The noninfectious etiology corresponded to 30 cases (31.6%). Conclusions: Tuberculosis in developing countries is still an important cause of skin lesions which must be studied via histopathological examination and culture due to their low bacillary load. A PCR test is necessary to obtain faster confirmation of the disease and to establish an early, specific and effective treatment.

Post-burn hypertrophic scars are characterized by increased collagen synthesis and hyperplasia, and may be associated with erythema, pain, dysesthesia, pruritus, and skin border elevation. Although the etiopathogenesis of hypertrophic scarring remains unclear, proinflammatory and profibrogenic cytokines are known to play an important role in general skin dysfunction. This study assessed mRNA expression, proteins, and type I receptors of tumor necrosis factor-alpha (TNF-α) and interleukin 1-beta (IL-1β) in normal skin, normotrophic and post-burn hypertrophic scars. Skin biopsies were obtained from 10 hypertrophic and 9 normotrophic scars, and 4 normal skin sites. Only post-burn scars covering more than 10% of the body were included. Ex vivo histopathological analysis evaluated scar maturity, in situ hybridization assessed mRNA expression, and cytokine protein and cytokine/cell colocalization were performed using single- and double-label immunohistochemistry, respectively. IL-1β is overexpressed in hypertrophic scars at the post-transcriptional level, associated primarily with keratinocytes and CD1a+ cells. Type I receptors for TNF-α are overexpressed in blood vessels of hypertrophic scars. The coordinated overexpression of IL-1β and TNF-α type I receptor may maintain the fibrogenic phenotypes of hypertrophic scars, even those in "remission".

A 25-year-old man from Coscomatepec, Veracruz (400 km south-east of Mexico City), and currently resident at this location, presented with dermatosis on the face, affecting the frontal region, dorsum of the nose, and malar region, composed of two nodular or verrucose plaques with an irregular diameter and form, with infiltrated borders, ulcerations, and bloody and honey crusts; the plaques developed over 4 years after trauma due to a horse kick (Fig. 1a.) Figure 1. (a) Initial appearance. (b) After 7 years of various treatments Download figure to PowerPoint Symptoms were moderate pruritus and some pain on examination. The patient had previously received topical treatment with steroids and procaine penicillin in an irregular form. At the beginning, the presumptive clinical diagnosis was verrucose tuberculosis; thus a tuberculin skin test (purified protein derivative, PPD) was applied with a response of 3 × 2 cm of induration and erythema; later, a biopsy was taken to confirm the diagnosis. Based on these results, antituberculosis treatment with ethambutol, 1.2 g/day, and isoniazid, 300 mg/day, plus copper sulfate baths, was instituted for 1 month. Histopathology revealed a parakeratotic epidermis with moderate irregular acanthosis; zones of spongiosis and exocytosis formed in some areas with crusts and cellular detritus. In the superficial and medial dermis layers, a wide inflammatory infiltrate formed from lymphocytes, epithelial histiocytes, some plasmocytes, and giant multinucleated Langhans-type cells and some dilated and congested capillary vessels were observed. Through Schiff’s and Grocott’s stains, long yeast-like structures of approximately 5–8 μm were observed. The histopathologic diagnosis was a tuberculoid granuloma with mycotic elements suggesting blastomycosis (Fig. 2). Figure 2. Skin biopsy: yeast cells of Sporothrix schenckii (Grocott’s stain, original magnification ×100) Download figure to PowerPoint Based on the histologic examination, the following mycologic tests were performed: direct examination with potassium hydroxide (KOH) and with Gram stain revealed yeast-like, oval and elongated cells of approximately 5–10 μm. Cultures of Sabouraud and Micosel agar grew Sporothrix schenckii. Skin tests of sporotrichin M and Y (from mycelial and yeast antigens) were applied several times at different concentrations, always with negative results; therefore, the immunologic profile was performed (summary in Table 1). Table 1. Immunologic features Antigens Skin tests MIF (%) MIF, macrophage inhibition factor. PPD (tuberculin) 3 × 2 cm 77 Candidin 2 × 2 cm 60 Trichophytin 1 × 1 cm 36 Streptokinase-streptodornase (varidase) Negative 20 Sporotrichin Y (yeast) Negative 0 Sporotrichin M (mycelial) Negative 0 Hematology, liver function tests, and urinalysis were within normal ranges. A chest X-ray was normal. The CD4/CD8 lymphocyte ratio was 1.25 cell/mm3, i.e. within normal values. Two evaluations of human immunodeficiency virus (HIV) antibodies performed in two different periods were negative to Western blot (WB) and enzyme-linked immunoabsorbent assay (ELISA) tests. During the past 8 years, we have observed the patient; he has received several treatments and has achieved considerable clinical improvement; nevertheless, each time treatment is discontinued, new superficial and discrete lesions appear with positive cultures to S. schenckii; sporotrichin tests were applied every year (8 times), and yielded a positive result. Figure 3 summarizes the treatment period as well as the drugs used. In summary, the patient was managed as follows: he initially received oral potassium iodide, 3–6 g/day for 8 months; this treatment was repeated many times in several episodes of reactivation of the disease or as supportive treatment; ketoconazole, 400 mg/day for 6 months; amphotericin B for 2 months at a dose level of 0.50 mg/kg/day; itraconazole, 300– Figure 3. Treatment and course of the disease Download figure to PowerPoint 400 mg/day for several treatment periods; fluconazole, 300 mg/day for 4 months; terbinafine, 500 mg/day for 4 months. During the use of all these systemic antimycotic agents, monitoring of hematology and renal and liver function tests were performed with no alterations observed. As a consequence of the initial trauma and its cicatrization, the patient presented retraction of the left eyelid, for which he underwent a surgical process; bridal tissues were released and a graft was placed later on with a satisfactory functional and cosmetic result. Currently, the patient is alternately taking, with resting periods of up to 3 months, potassium iodide at a dose of 0.5–1.0 g/day or itraconazole 100 mg/day. At the last visit (March 1998), the patient showed excellent clinical improvement; however, cultures are still positive.

Resumen —La vasculitis necrosante es una de las manifestaciones cutaneas del sindrome de anticuerpos antifosfolipidos, ya que dos terceras partes de los pacientes, que desarrollan este sindrome, presentan ulceras necroticas que pueden confundirse con ulceras de cualquier otra etiologia. La aparicion de estas ulceras esta asociada con mas frecuencia a la presencia de anticuerpos anticardiolipina que a la de anticoagulante lupico en sangre. Se presenta el caso de una paciente de 52 anos de edad con vasculitis necrosante asociada al sindrome de anticuerpos antifosfolipidos.

A 57-year-old male presented with dermatosis of the dorsum of the foot consisting of tumefaction, deformity and sinus tract formation. The direct examination of exudates as well as the biopsy tissue, demonstrated the presence of black granules. A dematiaceous fungus was isolated from the lesions and was identified by ribosomal DNA sequencing as Cladophialophora bantiana. This is the second report of this fungus as an etiologic agent of eumycetoma in humans. Clinical and mycologic cure was achieved after 20 months of treatment with itraconazole at a starting dose of 300 mg/day that was tapered during the course of therapy. The patient's isolate had an itraconazole MIC of 0.012 microg/ml.

A 30-year-old woman presented with a 1-year history of a pruritic eruption on the extremities, characterized by several annular plaques. The patient had been treated unsuccessfully with medium-potency topical steroids. The lesions had an erythematous papular border with an atrophic center (width, 1-4 cm) (Fig. 1). No oral, genital, or nail lesions were observed. A skin biopsy from one of the plaques was performed. Histopathologic examination of the raised border showed hyperkeratosis of the stratum corneum, focal thickening of the granular layer, basal liquefaction degeneration of the epidermis, and a band-like subepidermal infiltration with numerous Civatte bodies. In the center of the lesion, the epidermis became thinner (Fig. 2). Elastic fibers were reduced or absent in the papillary dermis. The patient was treated with high-potency topical steroids for 2 months with clinical improvement.

Skin tags are skin-colored, pedunculated tumors with a smooth surface. Histologically are composed by loose collagen fibers and dilated capillaries. Giant skin tags are reported rarely in the literature. We present the case of two giant skin tags on labium majus. To our knowledge, these are the largest skin tags reported.

Dermal dendrocyte hamartomas are extremely rare; only two examples have been described with clinical features different from our cases and with incomplete immunohistochemical characterization. We report three female patients presenting a medallion-shaped, well-defined, slightly atrophic and asymptomatic congenital lesion. All 3 patients showed a fusiform-cell proliferation. Immunohistochemistry was positive for CD34, factor XIIIa, and fascin. Electron microscopy showed typical features of dermal dendrocytes. We believe that the lesions described represent a new, clinically and histopathologically distinct lesion originating in dermal dendrocytes. We propose to name it medallion-like dermal dendrocyte hamartoma.

Sporotrichosis is a chronic granulomatous mycosis caused by a dimorphic fungus, Sporothrix schenckii. The most common manifestations of infection are lymphocutaneous and fixed-cutaneous types. In the case of immunosuppressed patients, and particularly in patients with acquired immune deficiency syndrome (AIDS), it occurs as disseminated cutaneous disease. This is a report of a 28-year-old male patient who presented with disseminated cutaneous and hematogenous sporotrichosis involving multiple ulcerative, nodular lesions in various body areas. Treatment consisted of 300 mg/d of itraconazole, which resulted in clinical and mycological cure.

Background: Information is scarce about the presence of molecular alterations related to human papillomavirus (HPV) infection in squamous cell carcinomas of the genital skin and about the effect of this infection in the number of Langerhans cells present in these tumors. Aims: To determine the presence of HPV in genital skin squamous cell carcinomas and to see the relationship between HPV infection and changes in the expression of Ki-67 antigen (Ki-67), p53 protein (p53), retinoblastoma protein (pRb) and E-cadherin and to alterations in Langerhans cell density, if any. Methods: A descriptive, comparative, retrospective and cross-sectional study was performed with all the cases diagnosed as squamous cell carcinomas of the genital skin at the Dermatopathology Service from 2001 to 2011. The diagnosis was verified by histopathological examination. The presence of HPV was examined using chromogenic in situ hybridization, and protein expression was studied via immunohistochemical analysis. Results: The 34 cases studied were verified as squamous cell carcinomas and 44.1% were HPV positive. The degree of expression of pRb was 17.50% ±14.11% (mean ± SD) in HPV-positive cases and 29.74% ±20.38% in HPV-negative cases (P = 0.0236). The degree of expression of Ki-67 was 47.67% ±30.64% in HPV-positive cases and 29.87% ±15.95% in HPV-negative cases (P = 0.0273). Conclusion: HPV infection was related to lower pRb expression and higher Ki-67 expression in comparison with HPV negative samples. We could not find a relationship between HPV infection and the degree of expression of p53 and E-cadherin or with Langerhans cell density.

Myxoid neurofibroma (MN) is a benign tumor of perineural cell origin, which is demonstrated with a positive immunohistochemical staining for S-100 protein. The most common locations of the MN are the face, shoulders, arms, periungual and in the feet. To our knowledge, this is the first time that a trunk location is reported. MN should be included in the differential diagnosis of tumors on this location.

Context: Rosacea significantly affects the quality of life and its pathophysiology is not well understood. It has been suggested that the presence of Demodex folliculorum in the affected skin could be related to the development of rosacea. Aims: To study the risk for association between the presence of D. folliculorum in skin biopsies and the diagnosis of rosacea. Settings and Design: Analytical, observational, retrospective, case-control study. Materials and Methods: Skin biopsies of patients diagnosed clinically as rosacea and the same number of controls were studied. The controls were selected among the facial skin biopsies that were not diagnosed as rosacea. All the slides were analyzed for the presence of D. folliculorum and the density of the infestation was assessed. Statistical Analysis Used: Absolute/relative frequencies, mean, standard deviation, odds ratio (OR), Chi square and Independent Student t-test with Epi Info v. 3.4.3͹ . Results: D. folliculorum was present in 80% of the skin biopsies of rosacea patients and in 30% of the controls. The risk of suffering rosacea was increased among persons infested with the mite (OR = 9.33 [95% confidence interval: 2.85-30.60]; P = 0.0001). The mean infestation density among the cases was 1.908 for every 10 high-power fields while it was 0.718 among the controls ( P < 0.005). There were no statistically significant differences among the groups with regard to sex and age. Conclusions: The presence of D. folliculorum in skin biopsies is associated with the diagnosis of rosacea. The infestation density was increased among the patients with rosacea.

Mycetoma is a chronic granulomatous disease, classified into eumycetoma caused by fungi and actinomycetoma due to aerobic filamentous actinomycetes. Mycetoma can be found in geographic areas near the Tropic of Cancer. Mexico is one of the countries in which actinomycetoma is endemic. We report an extraordinary case of an adult male with double eumycetoma caused by Madurella mycetomatis and Fusarium verticillioides on both feet.