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P8465Cutaneous Loxoscelism: A diagnosis to consider
Lauren Strazzula, Massachusetts General Hospital, Boston, MA, United States;Daniela Kroshinsky, Massachusetts General Hospital, Boston, MA, United States;William Tsiaras, Massachusetts General Hospital, Boston, MA, United States
A 17 year-old healthy female presented with a 1-month history of 2 adjacentnonhealing ulcers on her left lower leg, The patient had been awakened from sleep 1month prior with sharp calf pain while sleeping in a sleeping bag at a friend’s house.She noticed 2 pink papules at that time that subsequently became violaceous,bullous, and then ulcerated. She reported associated myalgias and mild arthralgias.The patient was subsequently seen by her primary care physician and received twocourses of sulfamethoxazole/trimethoprim for possible MRSA cellulitis. Because ofthe persistence of her symptoms, she then presented to the emergency departmentfor dermatologic evaluation. Review of photos taken by her family, her clinicalpresentation, and the morphology of her lesions were concerning for a Loxoscelesspider bite. Basic chemistries and hematology laboratories were within normallimits. A punch biopsy demonstrated an arthropod assault with toxin mediated fatnecrosis likely secondary to a Loxosceles spider bite. The toxins from venomousspider bites result in a local cutaneous reaction known as necrotic arachnidism. Inthe United States, Loxosceles reclusa (brown recluse spider) is the most commonspider associated with this phenomenon. The ‘‘red, white, and blue’’ sign describesthe initial erythema, subsequent toxin-mediated vasoconstricted pallisading ring,and ultimate bluish necrotic ulcer that is the pathognomic pattern of lesionprogression and was documented in this patient. Along with local necrosis, thespider’s toxins can rarely lead to systemic loxoscelism which can present with feverand myalgias and may progress to hemolytic anemia, DIC, and death. The patient inthis case was treated with local wound care and seen in the outpatient setting untilthe ulcers healed. Cutaneous loxoscelism is an important diagnosis to consider, assystemic involvement, while rare, may be fatal.
MAY 201
cial support: None identified.
CommerP8282Cutaneous RosaieDorfman disease coexisting with nontuberculousmycobacterial infection
Shang-Ian Tee, MBBS, National Skin Centre, Singapore, Singapore; Hiok Hee Tan,MBBS, Thomson Specialist Skin Centre, Singapore, Singapore
Cutaneous RosaieDorfman disease (RDD) is a rare benign histiocytic proliferativedisorder limited to the skin. Its eitiology is unknown, although viral infection waspostulated as a possible cause. We report a case of RDD in which nontuberculousmycobacterium (NTM) were found within the lesions on the skin. A 61-year-oldChinese female presented with a 5-month history of a slowly expanding asymp-tomatic 6-3 5-cm erythematous plaque on her right upper arm. She was otherwisein good health and did not recall preceding trauma. The regional lymph nodes werenot palpable. Skin biopsy revealed a diffuse and nodular infiltrate of histiocytesexhibiting emperipolesis of lymphocytes and plasma cells. Stains for CD68 and S100protein were positive within the histiocytes. Interestingly, acid fast bacilli were alsoseen on ZiehleNeelsen stain and polymerase chain reaction confirmed the presenceof NTM DNA. She was treated with a combination of oral ciprofloxacin 500 mg bdand clarithromycin 500 mg bd for 7 months, with clinical improvement in the sizeand thickness of the lesion. To our knowledge, the association of NTMwith RDD hasnot been reported before. The clinical improvement encountered with antibiotictreatment for NTM appears to support an infective eitiology for RDD in our patient,and should be considered in the work-up of cases in future.
cial support: None identified.
Commer4
P8100Delusional infestation presenting with shared delusions: Treatmentoutcomes from a case series
Alia Ahmed, MBBS, Barts Health NHS Trust, London, United Kingdom; AnthonyBewley, MBBS, Barts Health NHS Trust, London, United Kingdom; Reena Shah,PhD, Barts Health NHS Trust, London, United Kingdom; Ruth Taylor, MBBS, BartsHealth NHS Trust, London, United Kingdom
Background: Delusional infestation (DI) is the persistent belief of pathogenicinfestation of the skin or body, without objectivemedical evidence. Shared delusionscan occur between the index case and another individual (folie �a deux), and rarelyfolie �a trois may occur.
Objectives: The aim of this case review was to investigate treatment outcomes for aseries of patients who had DI coexistent with shared delusions (ie, folie �adeux/trois).
Methods: Three 3 patients who had a diagnosis of DI and shared delusions wereidentified from a specialist psychodermatology clinic database. Treatment measuresand outcomes for the index case and others involved were assessed via medicalrecords and patient letters.
Results: All the index cases suffered from DI (2 females, 1 male, age range 35-52years, mean age 42 years). Two index cases had a diagnosis of DIwith folie �a trois and1 case had DI with folie �a deux. The patients sharing the delusions were either thespouse of the index case and/or their children. Treatment of 2 of the index caseswith an atypical antipsychotic (risperidone) and topical treatment (includingantimicrobial emollient therapy) resulted in resolution of the symptoms. Thosesharing the delusions were treated topically and experienced symptom resolutionwithout systemic treatment once the index case had been treated. One index casedid not complywith risperidone andwas treated with a selective serotonin reuptakeinhibitor (citalopram); his wife also required the same treatment. Their symptoms,although improved, did not resolve completely.
Conclusions: This is the first case series report of treatment outcomes for patientspresenting with DI and shared delusions. It is important to ask patients when theypresent whether their spouse, children, or any other members of their family/-friends have similar symptoms. Treatment of the index case with risperidone andtopical treatment can result in resolution of symptoms. Those sharing the delusionscan be treated topically and symptoms usually resolvewithout systemic treatment. Itis likely once the index case experiences relief from symptoms, those sharing thedelusions will follow suit.
cial support: None identified.
CommerP8654Dermatitis herpetiformis: An entity probably underdiagnosed
Mar�ıa Salazar-Nievas, MD, San Cecilio Hospital, Granada, Spain; Juan M.Rubio-L�opez, MD, Jaen City Hospital Complex, Ja�en, Spain; VicenteCrespo-Lora, MD, San Cecilio Hospital, Granada, Spain
Overview: Dermatitis herpetiformis (DH) is a subepidermal bullous diseasecharacterized by chronic recurrence of itchy, erythematous papules, urticarialwheals and grouped vesicles that appear symmetrically on the extensor surfaces,buttocks and back.
Case report: A 46-year-old man born in Senegal was worried about the episodicappearance of erythematous and vesicular lesions on the trunk, legs, and arms sincelast 4 years. The patient did not show relevant medical history or other symptomsand denied drug intake. The examinations shown he presented small papular andvesicular lesions which were grouped in small plaques. The differential diagnosis ofeczema, impetigo, prurigo and bullous pemphigoidwas established. A punch biopsywas done with a sample taken from a lesion located in the right forearm. In thehematoxylineeosin staining is shown findings compatible with dermatitis herpeti-formis. The patient was treated with oral dapsona at doses of 50 mg/day and gluten-free diet with improvement.
Comment: Dermatitis herpetiformis is often underdiagnosed. It is importantsuspected this disease in patients with vesicular and papular lesions in areas ofextension, very itchy, and no improvement with corticosteroid treatment. Actually,because of immigration it is necessary that the dermatologists are trained todiagnose dermatoses in all skin types, especially skin color where physicalexamination can be more difficult. A correct and early diagnosis of dermatitisherpetiformis is essential as this disease is the cutaneous expression of a gluten-sensitive enteropathy identifiable with celiac disease.
cial support: None identified.
CommerJ AM ACAD DERMATOL AB41
