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Leishmaniasis can occur as an opportunistic infection in individuals with human immunodeficiency virus (HIV) and this presentation has been reported mainly from countries where leishmaniasis is endemic. However with changes in migration and travel patterns, leishmaniasis is now being diagnosed more frequently in non-endemic countries such as Australia. We report a case of diffuse cutaneous leishmaniasis presenting with violaceous and brown papules and superficial erosive plaques in a patient with severe HIV-associated immunosuppression who also was found to have histoplasmosis of the lymph nodes. This case highlights the need to consider leishmaniasis alongside other atypical infections that may co-exist in patients with HIV.

Introduction: Dynamic contrast-enhanced computed tomography (DCE-CT) and Positron Emission Tomography/Computed Tomography (PET/CT) have a high reported accuracy for the diagnosis of malignancy in solitary pulmonary nodules. The aim of this study was to compare the accuracy and cost-effectiveness of these. Methods: In this prospective multicentre trial, 380 participants with a solitary pulmonary nodule (8-30mm) and no recent history of malignancy underwent DCE-CT and PET/CT. All patients underwent either biopsy with histological diagnosis or completed CT follow-up. Primary outcome measures were sensitivity, specificity, and overall diagnostic accuracy for PET/CT and DCE-CT. Costs and cost-effectiveness were estimated from a healthcare provider perspective using a decision-model. Results: 312 participants (47% female, 68.1±9.0 years) completed the study, with 61% rate of malignancy at 2 years. The sensitivity, specificity, positive predictive value and negative predictive values for DCE-CT were 95.3% [95% CI 91.3;97.5], 29.8% [95% CI 22.3;38.4], 68.2% [95% CI 62.4%;73.5%] and 80.0% [95% CI 66.2;89.1] respectively, and for PET/CT were 79.1% [95% CI 72.7;84.2], 81.8% [95% CI 74.0;87.7], 87.3%[95% CI 81.5;91.5) and 71·2% [95% CI 63.2;78.1]. The area under the receiver operator characteristic curve (AUROC) for DCE-CT and PET/CT was 0.62 [95%CI 0.58;0.67] and 0.80 [95%CI 0.76;0.85] respectively (p<0.001). Combined results significantly increased diagnostic accuracy over PET/CT alone (AUROC=0.90 [95%CI 0.86;0.93], p<0.001). DCE-CT was preferred when the willingness to pay per incremental cost per correctly treated malignancy was below £9000. Above £15500 a combined approach was preferred. Conclusions: PET/CT has a superior diagnostic accuracy to DCE-CT for the diagnosis of solitary pulmonary nodules. Combining both techniques improves the diagnostic accuracy over either test alone and could be cost-effective. (Clinical trials.gov - NCT02013063).

Perioral ulcerative plaques have a broad list of differential diagnoses. We describe an unusual presentation of chronic progressive perioral ulceration due to herpes simplex type (HSV)-1 on a background of undiagnosed human immunodeficiency virus infection with acquired immunodeficiency syndrome. Whilst chronic mucocutaneous HSV is an AIDS-defining condition with both HSV-1 and HSV-2 implicated, typical reported cases describe vesicular eruptions rather than perioral ulcerative plaques. This case highlights that common infections may present atypically in immunocompromised individuals and may be a clue to underlying systemic illness.Copyright © 2019 The Australasian College of Dermatologists

Perioral ulcerative plaques have a broad list of differential diagnoses. We describe an unusual presentation of chronic progressive perioral ulceration due to herpes simplex type (HSV)-1 on a background of undiagnosed human immunodeficiency virus infection with acquired immunodeficiency syndrome. Whilst chronic mucocutaneous HSV is an AIDS-defining condition with both HSV-1 and HSV-2 implicated, typical reported cases describe vesicular eruptions rather than perioral ulcerative plaques. This case highlights that common infections may present atypically in immunocompromised individuals and may be a clue to underlying systemic illness.

Steven Johnson Syndrome (SJS) and toxic epidermolysis necrosis (TEN) are rare dermatological emergencies causing a painful mucocutaneous rash which bears a mortality rate of approximately 5%. This condition can be associated with systemic symptoms of fever, lymphadenopathy, hepatitis, cytopenias and cholestasis due to vanishing bile duct syndrome. Furthermore, epithelium from the respiratory tract and gastrointestinal lesions can also occur but cerebellitis is not known to co-exist with this disorder. We present a case of a 10 year old boy with SJS/TEN associated with cerebellitis. The patient presented with a 6 day history of a morbilliform desquamating rash affecting 25% of his total skin body surface area, fever, erosions of the oral, ocular and urethral mucosa and encephalopathy. The suspected aetiology was likely secondary to amoxicillin and a possible infection. Laboratory investigations identified an acute hepatitis, pancytopaenia with negative herpes simplex virus and mycoplasma mucosal swabs. Histology displayed lichenoid inflammatory changes with basal vacuolar degeneration, lymphocytic cell exocytosis and apoptosis consistent with SJS. Magnetic resonance imaging of the brain showed diffuse low signalling involving the brain stem and cerebellum suggestive of cerebellitis. We present findings from a literature review of evidence reporting cases of cerebellitis or neurological inflammation occurring alongside SJS/TEN.

Amniotic band sequence (ABS) is a group of congenital anomalies caused by in utero trauma from fibrous amniotic bands. ABS can rarely cause areas of absent skin at birth or Aplasia cutis congenita (ACC). We report a case of an otherwise healthy term male neonate, born via normal vaginal delivery, who presents at birth with extensive ACC of the right forearm and proximal hand. This is associated with underlying absence of subcutaneous tissue and muscle at the site and a congenital radial head dislocation. The neonate has a resting flexion deformity of the wrist and fingers due to the significant involvement of the extensor compartment of the forearm. The antenatal history was unremarkable with no maternal history of medications or infections during the pregnancy. There was no significant family history, including that of vascular disorders or ACC. The differential of Volkmann's ischemic contracture (VIC) was excluded due to the presentation. VIC is characterised by the rapid evolution of deep rupturing bullae which ulcerate and nectrotise due to ischemia from compartment syndrome that requires urgent fasciotomy. The remainder of the physical examination revealed no other abnormalities. Thus, associated syndromes with ACC (including Adams-Oliver, Bart and Setleis) were also excluded. Over the last six months, early and regular splinting, dressings and hand therapy have enabled continuing improvement in functioning of the hand. Large ACCs are typically managed with non-adherent dressings to conserve a moist environment and provide a physical barrier from pathogens and possible trauma. The contractures formed from the atrophic scarring may require future surgical intervention if current conservative measures begin to fail. This case highlights that timely recognition of this rare association and early aggressive intervention with splinting, hand therapy and appropriate dressings optimises outcome.

Angiosarcoma is a rare and aggressive malignant tumour affecting vascular endothelial cells that can affect any anatomical location. We report a case of an 84-year-old male who initially presented to our dermatology clinic with a two-months history of extensive yellow, dusky partially ecchymotic discolouration affecting the left cheek. Within two months, this discolouration became variegated, rapidly spreading to involve the forehead, occiput, left periorbital and left pre- and post-auricular regions. An associated indistinct mass around the left parotid region was also noted on examination. Histopathology of left zygoma and left cheek biopsy was consistent with classical angiosarcoma. The patient was treated with palliative radiotherapy to improve symptoms and improve quality of life which proved unsuccessful. Diagnosis of angiosarcoma is frequently late due to the early interpretation by the patient as a benign lesion similar to ecchymosis, which explains why most patients are not diagnosed prior to widespread metastasis. Its abysmal prognosis means that not only is a prompt diagnosis of paramount importance for clinician to make but also important is the efficacy of treatment options that we can offer patients. Herein we present an up to date review of current and new reported treatment options for angiosarcoma.

A 63-year-old woman presented to ED with acute onset vomiting, sore throat and altered mental status, following several days of intractable headache and malaise. She was hypotensive and developed rapidly evolving purpura. She was treated with IV ceftriaxone, penicillin and dexamethasone for presumed invasive meningococcal disease and transferred to ICU. Blood cultures grew Neisseria meningitidis subgroup-Y. Over 24 h, the patient progressed to purpura fulminans and multi-organ failure. Skin desquamation was noted on day-2 and frank blistering on day-3. Upon Dermatology review (day-4), there were widespread bullae (40% BSA) with positive Nikolsky sign and oral mucosal involvement. Skin biopsies showed a shallow, cell-poor subepidermal vesicle and full thickness epidermal necrosis. No dermal microvascular thrombosis or vasculitis, features commonly seen in infectious purpura fulminans (1), were seen. It was postulated this was either a TEN-like presentation of purpura fulminans, where epidermolysis is a well-known phenomenon (2), or concomitant TEN secondary to antibiotic therapy. Antibiotics were changed to moxifloxacin and she received three consecutive daily doses of IVIG 1 g/kg. There was improvement in other organ systems but the involved skin progressed to 70% BSA. She was transferred to the statewide burns service, however the skin changes were ultimately deemed too extensive for grafting/artificial skin and she passed away some days later. This case presents multiple learning opportunities, including the challenge in differentiating between purpura fulminans and TEN clinically and histologically, the importance of early recognition of both conditions to direct treatment, and changing incidence of N.meningitidis subgroups in Australia.