confocal microscopy of cutaneous larva migrans

P2311The fundamental role of the ‘‘ten tasks to prevent disability in buruliulcer’’

Manuela Boleira, MD, Policlinica Geral do Rio de Janeiro, Rio de Janeiro, Brazil;Ana Elisa Kiszewski, MD, Universidade Federal de Ciencias da Sa�ude de PortoAlegre, Rio de Janeiro, Brazil; Linda Lehman, MD, American Leprosy Missions, Riode Janeiro, Brazil; Omar Lupi, MD, PhD, Policlinica Geral do Rio de Janeiro, Riode Janeiro, Brazil

Buruli ulcer is the third in occurrence of all mycobacteriosis, after tuberculosis andleprosy. This infectious disease is caused by Mycobacterium ulcerans. It wasreported in more than 30 countries with an unclear epidemiology. The clinicalmanifestations vary from subclinical symptoms to nodules, areas of edema, andplaques, but the more typical presentation is a large ulcer, usually on the limbs.Despite the considerable knowledge about their clinical manifestations in someendemic countries, in other areas this diagnosis may be overlooked. Fortunately, ithas been recognized as an emerging health problem; physicians should be educatedabout Buruli ulcer, because the early diagnosis and treatment including measures toprevent disabilities are essential for good outcome. In 2009, Leman L et al developed‘‘Ten Tasks to Prevent Disability in Buruli Ulcer.’’ It has been shown that it canprevent or minimize disabilities. This program needs to be started from diagnosisand continues after medical discharge, when necessary. Patients’ quality of lifechanged dramatically when this strategy for prevention of disability came to beadopted in certain endemic areas, indicating its fundamental role in the therapeuticregimen against Buruli ulcer.

AB100

cial support: None identified.

P2312Botryomycosis: Great response to sulfametoxazol-trimetoprim

Marcelo Lyra, MD, FIOCRUZ Instituto de Pesquisas Carlos Chagas, Rio de Janeiro,Brazil; Ana Pinto, MD, FIOCRUZ Instituto de Pesquisas Carlos Chagas, Rio deJaneiro, Brazil; Antonio do Valle, MD, PhD, FIOCRUZ Instituto de PesquisasCarlos Chagas, Rio deJaneiro, Brazil; Melissa Kuhn, MD, FIOCRUZ Instituto dePesquisas Carlos Chagas, Rio de Janeiro, Brazil

Botryomycosis is a chronic, granulomatous, suppurative bacterial infection of theskin and subcutaneous. The main agent is Staphylococcus aureus. Clinically, it mayresemble cysts, abscesses, fistulae, nodules, plaques, or dirty and pus-dischargingulcers. Infiltration of the underlying tissues can occur and osteomielitis should beexcluded. Pathogenesis is not clear but experimental data suggest that it is related tobacterial strain, virulence, inoculum of bacteria, presence of foreign bodies, andprobably host immune response. For diagnosis, a deep wedge surgical biopsy or afine-needle aspiration of the material must be performed. Culture will usually showthe presence of S aureus. The biopsy can show one or more large granules togetherwith scattered microabscesses with pus and sinuses. Botryomycosis mimics bothmycetoma and actinomycosis and usually requires surgical intervention for cure.Major surgery is often required for patients, because the infection is usuallyunresponsive to seemingly appropriate medical therapy. We report a case of a43-year-old man living in Rio de Janeiro that works as a mechanic with long-termexuberant lesions on the right leg. Most lesions were ulcerous and some verrucousand there were multiple fistulae orifices draining pus without grains. He had anenlargement of the right leg with leather consistence associated with strong painand functional limitation. The lesions appeared 28 years ago and he was diagnosedand treated for botryomycosis with different antibiotics schemas with partialimprovement followed by relapse. A biopsy and cultures for fungi, micobacterias,and actinomyces were performed with negative results. The culture (originatedfrom the fistula’s secretion) resulted negative for fungi but was positive for S aureus.In the culture from the biopsy’s fragment, S aureus grew, too. At this time, weprescribed SMX-TMP 800/160 mg twice a day. During the following months, thepatient presented an expressive improvement on the lesions and the paindecreased, no more draining fistulae were noticed, and a reduction of the edemaoccurred.We could see neither flogistic signals and the functional movements of theright leg returned. The lesions disappeared completely and he presents only residualscars. He used SMX-TMP at the initial dose for 280 days. The importance of the casereported bellow is the rarity of the disease and its expressive response to a commonantibiotic although the long-term evolution.

cial support: None identified.

J AM ACAD DERMATOL

P2313Primary cutaneous nocardiosis caused by Nocardia transvalensis in animmunocompetent patient

Josep A. Pujol-Montcus�ı, MD, Hospital Universitari Joan XXIII, Tarragona, Spain;Laia Pastor-Jane, MD, Hospital Universitari Joan XXIII, Tarragona, Spain; MariaSimo-Esqu�e, MD, Hospital Universitari Joan XXIII, Tarragona, Spain; Maria LuisaDiaz, MD, Hospital Universitari Joan XXIII, Tarragona, Spain; Pilar Tur�egano-Fuentes, MD, Hospital Universitari Joan XXIII, Tarragona, Spain

Case report: A 81-year-old man with no factors of immunosuppression presentedwith an indurated, granulomatous, and friable tumor-like mass on the back of his lefthand, with multiple draining sinuses. He was otherwise healthy, and referred aprevious superficial wound 1 week before the consultation. Histologic studyshowed a pseudoepitheliomatous hyperplasia, without identifying germs or signssuggestive of malignancy. Cultivation from smears and tissue culture of several skinbiopsies showed a Nocardia spp, which was identified as Nocardia transvalensis.Treatment with intravenous ceftriaxone for 1 month was prescribed, followed byoral therapy with trimethoprim-sulfamethoxazole. After 15 days of treatment, thisdrug caused gastric intolerance, so it had to be replaced by levofloxacin. The lesionimproved slowly until complete resolution, 2 months after the beginning oflevofloxacin.

Discussion: Cutaneous nocardiosis presents either as a part of a disseminatedinfection or as a primary infection resulting from inoculation. Primary cutaneousnocardiosis is relatively rare, and may present as an acute cutaneous infection(cellulitis or abscesses), a lymphocutaneous infection, and mycetoma, a deeperinfection. Mycetoma is uncommon in immunocompetent patients. The initialclinical diagnosis may be difficult because of the nonspecific clinical picture, andmay cause a delay in diagnosis. Demonstration of the organism from clinicalspecimens is the mainstay of diagnosis. N transvalensis is a rare Nocardia speciesthat has previously been recognized as a cause of actinomycotic mycetoma. Ntransvalensis can produce pneumonia or disseminated infection in immunocom-promised patients. Cutaneous nocardiosis can be cured with a course of antimicro-bial treatment of 1 to 3months. In deep cutaneous nocardiosis, to prevent the risk ofdissemination, parenteral therapy is recommended for 1 month, followed by oralantibiotic therapy (usually trimethoprim-sulfamethoxazole) for at least 2 monthsuntil complete healing. Sometimes it is necessary to perform surgical drainage ofabscesses or debridement of necrotic tissue.

Conclusion: We report a case of atypical presentation of nocardiosis caused by Ntransvalensis in the form of suppurative tumor in an immunocompetent patient.

cial support: None identified.

P2314Confocal microscopy of cutaneous larva migrans

Richard Langley, MD, Dalhousie University, Halifax, Nova Scotia, Canada; AmandaWebb, Dalhousie University, Halifax, Nova Scotia, Canada; David Haldane, MD,Capital District Health Authority, Halifax, Nova Scotia, Canada; Kerri Purdy, MD,Dalhousie University, Halifax, Nova Scotia, Canada; Noreen Walsh, MD,Dalhousie University, Halifax, Nova Scotia, Canada

Background: Confocal scanning laser microscopy (CSLM) is a recently developedhigh resolution modality currently employed in experimental and clinical derma-tology. In the current report CSLMwas used to image cutaneous larva migrans. A 38-year-old man presented with a pruritic serpiginous eruption on the plantar aspect ofthe right foot that had developed on his return from a trip to Mexico. Clinicaldiagnosis of cutaneous larva migrans was made.

Methods: Clinical images and confocal microscopy (Vivascope 1500; Lucid,Henrietta, NY) images were obtained of the lesion. In addition, a 4-mm punchbiopsy specimen was taken at the site where confocal microscopy was performed.

Results: Imaging readily identified a dark, 3-mm wide disruption in the normalhoneycomb pattern of the epidermis corresponding to the larval burrow, and ahighly refractile oval larva. Histopathology revealed the intact hookworm larvawithin the richly eosinophilic epidermis on routine histology.

Discussion: CSLM provided an effective way to track and locate a hookworm larvaand allow for precise excision as a rapid treatment method in this case of cutaneouslarva migrans.

cial support: None identified.

FEBRUARY 2011