Treatment with rituximab in 37 patients with pemphigus vulgaris

(Poster reference number 4816)Agustin Espa~na, MD, University Clinic of Navarra, Pamplona, Spain; JosepHerrero-Gonzalez, MD, Hospital Del Mar, Barcelona, Spain; Pilar Iranzo, MD,Clinic Hospital of Barcelona, Barcelona, Spain; Ricardo Suarez, MD, GregorioMara~n�on’s Hospital, Madrid, Spain

Introduction: Pemphigus vulgaris (PV) is an autoimmune blistering skin diseasecharacterized by acantholysis and autoantibodies against desmoglein 1/3. Treatmentof PV is based on corticosteroid and immunosuppressive drugs administration.Recently, rituximab (Rtx) treatment has been successful in PV patients.

Methods: Herein, we present our experience in 37 PV patients treated with Rtx andanalyzed in four different hospitals of Spain: University Clinic of Navarra, ClinicHospital of Barcelona, Gregorio Mara~n�on’s Hospital of Madrid and Hospital del Marof Barcelona. The average of patients was 49 years. Overall, all patients had receivedcorticosteroids and/or immunosuppressive drugs before Rtx treatment for 3 years asan average. Rtx was begun when either corticosteroids were not successful enoughor other immunosuppressive drugs were contraindicated. Four different Rtxtreatment schedules were analyzed: (a) Rtx (375 mg/m2 for 4 sessions) plusprednisone (0.5-0.7 mg/kg) (28 patients); (b) Rtx plus prednisone plus immuno-suppressive drugs plus gammunoglobulins (3 patients); (c) Rtx plus prednisone plusgammaglobulins (4 patients); (d) Rtx plus prednisone plus immunosuppressivedrugs (1 patient); and (e) Rtx alone (1 patient). All patients were regularly followedup clinically and immunologically.

Results: All patients experienced a favorable clinical response. No side effects afterRtx treatment were found. 78% of patients needed more than 1 Rtx cycle to achievecontrol of PV lesions. Differences in response among the five therapeutic scheduleswere not observed. Response to Rtx was not related with either chronic stage of PVlesions or previous treatments.

Conclusion: (1) Rtx is a safe and effective treatment for PV; (2) Rtx was indicatedwhen high dose corticosteroids were necessary to control PV manifestations orwhen relevant drug side effects were observed; (3) the schedule consisting of Rtx(375 mg/m2 for 4 sessions) plus prednisone (0.5-0.75 mg/m2) was a successfultherapeutic option inmost PV patients. In our hands, additional immunosuppressivedrugs adjuvant to Rtx did not provide with any additional benefit in PV treatment;(4) new schedules of Rtx treatment should be considered to avoid new PV relapsesand side effects from chronic steroid use.

AB106

cial support: None identified.

Commer

INFECTION—BACTERIAL & PARASITIC

A case report and review of Mycobacterium marinum

(Poster reference number 5287)Geeta Patel, DO, Virginia College of Osteopathic Medicine/Lewis GaleMontgomery Regional Hospital, Blacksburg, VA, United States; Chad Johnston,DO, Virginia College of Osteopathic Medicine/Lewis Gale Montgomery RegionalHospital, Blacksburg, VA, United States; Daniel Hurd, DO, Virginia College ofOsteopathic Medicine/Lewis Gale Montgomery Regional Hospital, Blacksburg,VA, United States

Atypical mycobacterial infections are increasingly important in immunosuppressedpatients as well as in healthy hosts. The atypical mycobacterium that mostcommonly affects the skin is Mycobacterium marinum. Key elements in thediagnosis of this infection are a high index of suspicion based on the presence ofulcers, nodules or chronic plaques, a history of contact with fresh or salt water, andtissue biopsy for culture and histology. AsMmarinum does not grow under routineculture conditions, the diagnosis is easily missed resulting in delayed treatment. Thetreatment is essentially antimicrobial therapy for the superficial lesions supple-mented by an appropriate surgical debridement especially when deep structures areinvolved. We report a case of M marinum infection in a patient receivingimmunosuppressive therapy that failed to respond to original treatment withminocycline and was placed on rifampin. We reviewMmarinum infection and thedifferent antibiotic regimens used for treatment.

cial support: None identified.

Commer

J AM ACAD DERMATOL

Bilateral cutaneous larva migrans

(Poster reference number 4677)Isabel Cristina Valente Duarte De Sousa, MD, Centro Dermatologico Dr. LadislaoDe La Pascua, Delegacion Cuahutemoc, Distrito Federal, Mexico

Cutaneous larva migrans (CLM), also known as creeping eruption, is a migratorycutaneous eruption caused by the invasion and migration of parasitic larva in theskin, most commonly by Ancylostoma brasiliense or Ancylostoma caninum. It hasa worldwide distribution but is endemic in tropical and subtropical countries suchas the Caribbean, Africa, South America, Southeast Asia, and the central andsoutheastern states of the US. Hours to weeks after direct contact with intact skin,the larvae penetrate the epidermis and cause the appearance of an intensely pruriticerythematous papule or vesicle that later evolves to a serpiginous erythematous,pruritic or painful migrating tract that lasts 2-8 weeks. Common sites of exposureinclude feet, hands and buttocks. Diagnosis is based on history and clinicalsymptoms. A skin biopsy is usually not helpful because the actual location of thelarvae is 1-2 cm beyond the erythematous tract, and thus is not recommended as adiagnostic procedure. Rarely, peripheral eosinophilia and increased immunoglob-ulin E levels may be seen. Although CLM is usually a benign and self-limited disease,treatment is necessary because of possible complications and intense pruritus.Treatment with a single oral dose of ivermectin has been documented to be 80 to100% successful without any side effects. A 28-year-old woman developed erythem-atous bullous serpiginous tracts on both feet 20 days after walking barefoot at abeach in Mexico. The lesions were highly pruritic, painful, and migratory. Completeblood count and chest radiograph showed absence of eosinophilia and pulmonaryinfiltrates. A diagnosis of bilateral cutaneous larva migrans was made and treatmentwith a single dose of ivermectin (12 mg) was initiated. The patient was free oflesions 2 weeks later. Although cutaneous larva migrans is the most commontropically acquired dermatosis, lesions are usually unilateral, and bilateral affection isnot commonly observed.

cial support: None identified.

Commer

Borderline tuberculoid leprosy mimicking mycosis fungoides: Case report

(Poster reference number 5196)Elva D. Rodriguez-Acosta, MD, Instituto Nacional de Ciencias M�edicas y Nutrici�onSalvador Zubir�an, Mexico City, Mexico; Judith Dominguez-Cherit, MD, InstitutoNacional de Ciencias M�edicas y Nutrici�on Salvador Zubir�an, Mexico City, Mexico;Marcela Saeb-Lima, MD, Instituto Nacional de Ciencias M�edicas y Nutrici�onSalvador Zubir�an, Mexico City, Mexico; Roberto Arenas-Guzm�an, MD, HospitalGeneral Manuel Gea Gonz�alez, Mexico City, Mexico

We describe a 65-year-old man who presented with skin lesions highly suggestive ofmycosis fungoides. The patient was referred for evaluation of a worsening skindisease clinically diagnosed as sarcoidosis but unresponsive to steroidal treatment. Itwas a bilateral and symmetric dermatosis disseminated to the trunk, superior andinferior extremities. It consisted of multiple erythematous and squamous plaqueswith well-defined borders. Fever and weight loss, were noted two years prior toreferral. The differential diagnosis included mycosis fungoides and cutaneoussarcoidosis; therefore, the corresponding diagnostic procedures were made. Thecomputed tomography and general laboratory test were negative. The histopathol-ogy features demonstrated a sarcoidal granulomatous dermatitis without neurotro-pism. FiteeFaraco and auramina-rodamina were positive for Mycobacteria. Duringhis follow-up, the patient developed within weeks, dysesthesia at palms and soles,skin thickening and erythema developed, especially on the neck and face, madarosisand a leonine facies developed. With the diagnosis of leprosy a baciloscopy ofcutaneous lymph and nasal secretion was perform and resulted positive as well asMitsuda test. The antileprosy treatment was initiated with favorable response,clearing approximately 20% of the skin plaques at first month of therapy. This caseemphasizes the extensive differential diagnosis of leprosy, as well as the importanceof obtaining skin biopsies for diagnostic confirmation.

cial support: None identified.

Commer

APRIL 2012