|Year : 1990 | Volume
| Issue : 1 | Page : 58-60
Vijay Kumar, BR Garg, MC Baruah
Source of Support: None, Conflict of Interest: None
Seven cases of blastomycosis like pyo4erma without, any systemic were treated with a combination of antibiotics and corticosteroids, with good results. The number of lesions from one to ten and were present on the extremities. All the patients were having eosinophilia with an increased ESR, Staphylococcus aureus was the commonest micro-organism isolated there was no underlying medical problem in any patient.
Keywords: Blastomycosis-like pyoderma
|How to cite this article:|
Kumar V, Garg B R, Baruah M C. Blastomycosis-like pyoderma. Indian J Dermatol Venereol Leprol 1990;56:58-60
Blastomycosis-like pyoderma is an uncommon condition, first described by Azua and Pons in 1903 under the title of Pseudoepitheliomas cutanes. Later, similar cases were described as pyoderma chronica vegetans von Azua, pseudoepitheliomas of Azua, mycosis-like pyoderma and blastomycosis-like pyoderma.,, The only report from India on blastomycosislike pyoderma was in 1985 by Mohan Singh et al. We reviewed seven such cases seen in our hospital during the last 5 years.
| Materials and Methods|| |
The records of seven patients of blastomycosis-like pyoderma seen in our hospital from 1983 to 1987 were studied for the morphology of the lesions, systemic associations, investigations, treatment and follow-up. Five patients were treated with cotrimoxazole 2 tablets twice daily and 20 mg prednisolone daily for 2 weeks in tapering doses. Only one patient was given erythromycin 500 mg 4 times a day for 2 weeks instead of cotrimoxazole.
| Results|| |
The seven patients, 6 men and 1 girl, aged 16 to 65 years, had their skin lesions for 6 months to 1 year. The number of lesions ranged from one to ten. Lesions were present on the extremities [Figure - 1] except in two where abdomen and back were also involved. In all the patients, the lesions started as one or two pustules which gradually increased in size forming irregular plaques of varying sizes, having an exudative, verrucous, raised periphery studded with multiple small pusfilled cavities covered by crusts. The centre of the plaques was an atrophic scar. There was no lymphadenopathy. Two patients were having strongly positive tuberculin test but there was no evidence of tuberculosis anywhere in the body. All the patients were having eosinophilia with an increased ESR. Other investigations like stools, urine, liver function tests and blood VDRL were normal. AFB smear and fungal culture were negative.
Histopathology [Figure - 2] showed hyperkeratosis with acanthosis leading to pseudoepitheliomatous hyperplasia. Microabscesses were seen in the upper part of the epidermis containing neutrophils and erythrocytes. In the dermis, there was an intense inflammatory infiltrate containing neutrophils and erythrocytes. Giant cells or granuloma were not seen.
Staphylococcus aureus was grown in all the patients while beta-hemolytic streptococcus was grown only in 3 patients. Organisms were susceptible to erythromycin, gentamicin and chloramphenicol in 5 patients, while in 2 there was resistance to penicillin, streptomycin, chloramphenicol, tetracycline, erythromycin, kanamycin, gentamicin and ampicillin. Most of our patients responded readily to courses of cotrimoxazole and prednisolone with infrequent recurrences observed in only 2 patients which responded well to the same treatment again, continued for a longer period.
| Comments|| |
The terminological confusion of blastomycosis-like pyoderma described in the earlier literature,,, is now a well established entity. Various associations described with this entity do not reflect a set pattern. Only seven cases seen by us in a period of 5 years reflect the rarity of this unusual tissue reaction to bacterial infection. Staphylococcus aureus was the commonest microorganism isolated in our cases like Su et al and Singh et al.
The diagnostic criteria put forward by Su et al' include large verrucous plaques with multiple pustules and an elevated border, pseudoepitheliomatous hyperplasia with abscesses in tissue biopsy specimens, growth of at least one of the pathogenic bacteria such as Staphylococcus aureus, beta-hemolytic streptococci or Pseudornonas aeruginosa, negative culture for deep fungi, atypical mycobacteria and Mycobacterium tuberculosis, a negative fungal serology test result, and normal bromide level in the blood. All our patients fulfilled these criteria except the fungal serology and bromide level in the blood which were not estimated as the history and examination did not point to such etiological agents. In most of our patients, antibiotic therapy alone did not help. The organisms were secondary invaders and corticosteroids were necessary for healing. Recurrences did not have bacteria at least in the early phases. Thus, these cases are not primarily a pyoderma, these rather closely simulate pyoderma gangrenosum which too was excluded by careful clinico-histopathological evaluation.
Unlike other studies,,, where underlying factors like chronic granulocytic leukemia, azathioprine and prednisolone therapy for arthritis, X-radiations, chronic cholecystitis, pulmonary granuloma, diabetes mellitus or alcoholism were recorded in association with this entity, we did not observe any such or other underlying factors in our patients even on longitudinal follow-up of upto 3 years. The interesting findings observed by us were eosinophilia, high ESR and negative tuberculin test. High ESR may be due to chronic skin infection causing tissue destruction. For the other two, we do not have any definite explanation. Absence of any underlying medical problem even on long follow up in our cases and the moderate response to antibiotics and anti-inflammatory agents suggest an altered response of skin to bacterial invasion in this disease.
| References|| |
|1.||Azua DJ and Pons CS : Pseudo-epithelioma cutanes, abstracted, Ann Dermatol Syphilol, 1903; 4 : 745746. |
|2.||Gay PJ and Cascos MA : Uber die pyodermitis chronica vegetans von Azua, Dermatologica, 1951; 103 : 135-144. |
|3.||Russell BF : Case for diagnosis. Granulomatous mycosis? Squamous carcinoma? Brit J Dermatol, 1953; 65 : 378. |
|4.||Brown CS and Kligman AM : Mycosis-like pyoderma, Arch Dermatol, 1957; 75 : 123-125. |
|5.||Yaffee HS : Localised blastomycosis-like pyoderma occurring in a tattoo, Arch Dermatol, 1960; 82 99-100. |
|6.||Williams HM and Stone OJ : Blastomycosis-like pyoderma, Case report of unusual entity with response to curettage, Arch Dermatol, 1966; 93 226-228. |
|7.||Su WPD, Duncan SC and Perry HO : Blastomycosis-like, pyoderma, Arch Dermatol, 1979; 115 170-173. |
|8.||Mohan Singh, Bhushan Kumar, Kaur S et al Blastomycosis-like pyoderma, Ind J Dermatol Venereol Leprol, 1985; 51 : 226-228. |
[Figure - 1], [Figure - 2]