Zoonotic Majocchi's Granuloma of the Vulva.

A healthy 32-year-old woman presented to clinic with tender pruritic lesions of 2-month duration at the vulva and lesions for weeks on the shins. She was treated with topical corticosteroids and intravenous vancomycin without significant improvement. On examination, dozens of follicular hemorrhagic papulopustules were detected at the suprapubic area and vulva (Figure 1). Similar but less prominent lesions were observed on the shins as well. Biopsies of the vulva and shin revealed a follicular inflammatory infiltrate of neutrophils, histiocytes, and lymphocytes as well as fungal hyphae within the follicular infundibulum and hair shafts, consistent with Majocchi's granuloma (MG). Gram and Fite-Faraco staining, direct immunofluorescence, and bacterial culture were negative. Tissue culture grew Trichophyton mentagrophytes, which was identified using sequence analysis of the D1/D2 region of the 28s rDNA. Minimum inhibitory concentrations for terbinafine, ketoconazole, and itraconazole were determined, with terbinafine having the lowest concentration. Additional history revealed that shortly prior to commencement of her clinical manifestations, the patient had acquired a pet guinea pig with eruptions and hair loss (Figure 2). The patient was prescribed ketoconazole cream and terbinafine, 250 mg daily, with almost immediate improvement. Based on clinical response, the patient remained on terbinafine and ketoconazole cream for 6 months. Her skin remained clear 4 months after discontinuing all antifungals. Based on the results of patient's culture, a veterinarian treated her guinea pig successfully with systemic terbinafine and miconazole lotion.

Blue Papules in a Child: Family History Might Prevent Diagnostic Tears.

A healthy 14-month-old boy presented with firm and grouped blue papules in the right mid area of the back and the right peri-anal area (Figure 1). The lesions first appeared when the boy was a 6- or 9-month old, gradually increasing in number to a total of six lesions. The child was delivered full-term with no complications, had no medical issues, and no personal or family history of gastrointestinal bleeding or anemia.

Acquired Lymphangiectasia in the Setting of a Gastrointestinal Stromal Tumor.

A 53-year-old woman presented for a skin cancer screening and was found to have scattered violaceous papulovesicles on the right buttock and right lower aspect of the abdomen. These lesions had been increasing in number for 3 years. The patient denied pain or pruritis at the site of lesions and denied any systemic fi ndings.

Human Papillomavirus and Genital Warts: A Review of the Evidence for the 2015 Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines.

To provide updates for the 2015 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines on human papillomavirus (HPV) and anogenital warts (AGWs), a review of the literature was conducted in key topic areas: (1) epidemiology and burden of disease; (2) transmission and natural history; (3) diagnosis and management of AGWs; (4) occupational exposure of healthcare workers; (5) anal cancer screening among men who have sex with men (MSM); and (6) HPV vaccine recommendations. Most sexually active persons will have detectable HPV at least once in their lifetime; 14 million persons are infected annually, and 79 million persons have prevalent infection. HPV is transmitted frequently between partners; more frequent transmission has been reported from females to males than from males to females. A new formulation of imiquimod (3.75% cream) is recommended for AGW treatment. Appropriate infection control, including performing laser or electrocautery in ventilated rooms using standard precautions, is recommended to prevent possible transmission to healthcare workers who treat anogenital warts, oral warts, and anogenital intraepithelial neoplasias (eg, cervical intraepithelial neoplasia). Data are insufficient to recommend routine anal cancer screening with anal cytology in persons living with human immunodeficiency virus (HIV)/AIDS or HIV-negative MSM. An annual digital anorectal examination may be useful for early detection of anal cancer in these populations. HPV vaccine is recommended routinely for 11- or 12-year-olds, as well as for young men through age 21 years and young women through age 26 years who have not previously been vaccinated. HPV vaccine is also recommended for MSM, people living with HIV/AIDS, and immunocompromised persons through age 26 years.

Scabies and Bacterial Superinfection among American Samoan Children, 2011-2012.

BACKGROUND: Scabies, a highly pruritic and contagious mite infestation of the skin, is endemic among tropical regions and causes a substantial proportion of skin disease among lower-income countries. Delayed treatment can lead to bacterial superinfection, and treatment of close contacts is necessary to prevent reinfestation. We describe scabies incidence and superinfection among children in American Samoa (AS) to support scabies control recommendations. METHODOLOGY/PRINCIPAL FINDINGS: We reviewed 2011-2012 pharmacy records from the only AS pharmacy to identify children aged ≤14 years with filled prescriptions for permethrin, the only scabicide available in AS. Medical records of identified children were reviewed for physician-diagnosed scabies during January 1, 2011-December 31, 2012. We calculated scabies incidence, bacterial superinfection prevalence, and reinfestation prevalence during 14-365 days after first diagnosis. We used log binomial regression to calculate incidence ratios for scabies by age, sex, and county. Medical record review identified 1,139 children with scabies (incidence 29.3/1,000 children aged ≤14 years); 604 (53%) had a bacterial superinfection. Of 613 children who received a scabies diagnosis during 2011, 94 (15.3%) had one or more reinfestation. Scabies incidence varied significantly among the nine counties (range 14.8-48.9/1,000 children). Children aged <1 year had the highest incidence (99.9/1,000 children). Children aged 0-4 years were 4.9 times more likely and those aged 5-9 years were 2.2 times more likely to have received a scabies diagnosis than children aged 10-14 years. CONCLUSIONS/SIGNIFICANCE: Scabies and its sequelae cause substantial morbidity among AS children. Bacterial superinfection prevalence and frequent reinfestations highlight the importance of diagnosing scabies and early treatment of patients and close contacts. Investigating why certain AS counties have a lower scabies incidence might help guide recommendations for improving scabies control among counties with a higher incidence. We recommend interventions targeting infants and young children who have frequent close family contact.

Acute rheumatic fever and rheumatic heart disease among children--American Samoa, 2011-2012.

Acute rheumatic fever is a nonsuppurative, immune-mediated consequence of group A streptococcal pharyngitis (strep throat). Recurrent or severe acute rheumatic fever can cause permanent cardiac valve damage and rheumatic heart disease, which increases the risk for cardiac conditions (e.g., infective endocarditis, stroke, and congestive heart failure). Antibiotics can prevent acute rheumatic fever if administered no more than 9 days after symptom onset. Long-term benzathine penicillin G (BPG) injections are effective in preventing recurrent acute rheumatic fever attacks and are recommended to be administered every 3-4 weeks for 10 years or until age 21 years to children who receive a diagnosis of acute rheumatic fever. During August 2013, in response to anecdotal reports of increasing rates of acute rheumatic fever and rheumatic heart disease, CDC collaborated with the American Samoa Department of Health and the Lyndon B. Johnson Tropical Medical Center (the only hospital in American Samoa) to quantify the number of cases of pediatric acute rheumatic fever and rheumatic heart disease in American Samoa and to assess the potential roles of missed pharyngitis diagnosis, lack of timely prophylaxis prescription, and compliance with prescribed BPG prophylaxis. Using data from medical records, acute rheumatic fever incidence was calculated as 1.1 and 1.5 cases per 1,000 children aged ≤18 years in 2011 and 2012, respectively; 49% of those with acute rheumatic fever subsequently received a diagnosis of rheumatic heart disease. Noncompliance with recommended prophylaxis with BPG after physician-diagnosed acute rheumatic fever was noted for 22 (34%) of 65 patients. Rheumatic heart disease point prevalence was 3.2 cases per 1,000 children in August 2013. Establishment of a coordinated acute rheumatic fever and rheumatic heart disease control program in American Samoa, likely would improve diagnosis, treatment, and patient compliance with BPG prophylaxis.

Congenital syphilis investigation processes and timing in Louisiana.

BACKGROUND: Congenital syphilis (CS) is a potentially life-threatening yet preventable infection. State and local public health jurisdictions conduct investigations of possible CS cases to determine case status and to inform public health prevention efforts. These investigations occur when jurisdictions receive positive syphilis test results from pregnant women or from infants. METHODS: We extracted data from Louisiana's electronic case management system for 328 infants investigated as possible CS cases in 2010 to 2011. Using date stamps from the case management system, we described CS investigations in terms of processes and timing. RESULTS: Eighty-seven investigations were prompted by positive test results from women who were known to be pregnant by the health jurisdiction, and 241 investigations were prompted by positive syphilis test results from infants. Overall, investigations required a median of 101 days to complete, although 25% were complete within 36 days. Investigations prompted by positive test results from infants required a median of 135 days to complete, and those prompted by positive test results from pregnant women required a median of 41 days. CONCLUSIONS: Three times as many CS investigations began with reported positive syphilis test results from infants as from pregnant women, and these investigations required more time to complete. When CS investigations begin after an infant's birth, the opportunity to ensure that women are treated during pregnancy is missed, and surveillance data cannot inform prevention efforts on a timely basis. Consistently ascertaining pregnancy status among women whose positive syphilis test results are reported to public health jurisdictions could help to assure timely CS prevention efforts.

Prevaccine era human papillomavirus types 6, 11, 16 and 18 seropositivity in the U.S.A., National Health and Nutrition Examination Surveys, 2003-2006.

BACKGROUND: A vaccine is available to prevent human papillomavirus (HPV) 6, 11, 16 and 18; in the prevaccine era, seropositivity to vaccine types is a measure of natural exposure. METHODS: We describe HPV seropositivity in the USA among 14-59-year-olds using the 2003-2006 National Health and Nutrition Examination Surveys. RESULTS: Seropositivity to HPV 6, 11, 16 and 18 was 17.5%, 6.8%, 15.1% and 5.9%, respectively, among women, and 7.0%, 2.4%, 5.2% and 1.5%, respectively, among men. Overall in both sexes, seropositivity was 22.5% for any vaccine type (31.8% in women and 12.9% in men), but substantially lower for three or more types (1.7% overall, 2.8% in women and 0.6% in men). CONCLUSIONS: Almost a quarter of the participants were seropositive to any HPV vaccine type but few were seropositive to at least three vaccine HPV types in the prevaccine era. Further study is needed to assess if seropositivity would be useful as a biological marker of vaccination.

Coxsackievirus A6-induced hand-foot-mouth disease.

IMPORTANCE: Hand-foot-mouth disease (HFMD) is an acute, self-limited, highly contagious viral illness that commonly affects children younger than 5 years. It is most typically caused by enterovirus 71 or coxsackievirus A16 and results in asymptomatic infection or mild disease. Immunocompetent adults are rarely affected. Recently, there have been increasing reports of a more severe form of HFMD associated with fevers, joint pains, and widespread painful eruptions. Some of these patients required hospitalization for supportive care. These severe cases were most commonly caused by coxsackievirus A6. OBSERVATIONS: We describe a 37-year-old white man with widespread, crusted, pruritic papules on the scalp, ears, and face and a purpuric and targetoid painful vesicular eruption on his hands and feet, with associated fevers, neurologic symptoms, and arthritis, who required hospitalization for supportive care. His infection with coxsackievirus A6 was confirmed based on polymerase chain reaction from his oral mucosa and cutaneous vesicle fluid. CONCLUSIONS AND RELEVANCE: Dermatologists should be familiar with the severe variant of HFMD caused by coxsackievirus A6, include it in their differential diagnosis of acute febrile blistering diseases, and be aware that certain patients may require hospitalization.

Expedited partner therapy in federally qualified health centers--New York City, 2012.

BACKGROUND: Management of patients' sex partners is a critical element of sexually transmitted disease (STD) control. Expedited partner therapy (EPT), a practice in which patients deliver medication or a prescription directly to their partners, is one option for partner management. As of 2009, New York State law specifically allows EPT for chlamydial infection. Federally qualified health centers (FQHCs) in New York City (NYC) care for patients at risk for STDs. We describe the policies and practices surrounding EPT and other STD management in NYC FQHCs. METHODS: In 2012, we surveyed medical directors at all NYC FQHC parent entities and clinicians at a sample of their corresponding clinical sites about written policies and actual practices regarding EPT for chlamydial infection and other STD management. RESULTS: Twenty-two entities (22/29; 76%) and 51 sites (51/72; 70%) responded to the survey. More than half of entities have a written policy permitting EPT, and 80% of sites provide EPT. Most entity policies allow EPT for, and most sites provide EPT to, adolescents and adults with both opposite-sex and/or same-sex partners. Most sites use electronic health records and provide EPT by prescriptions, and one third of sites do not provide educational materials with EPT. CONCLUSIONS: Our results indicate widespread EPT provision by NYC FQHCs; however, areas for improvement exist, specifically in following guidelines that recommend providing educational materials with EPT and do not recommend EPT for men with male partners. The use of prescriptions for EPT and electronic health records were identified as potential barriers to EPT provision.

Prevalence of circumcision among men and boys aged 14 to 59 years in the United States, National Health and Nutrition Examination Surveys 2005-2010.

BACKGROUND: In 2009, an estimated 3590 new heterosexually acquired HIV infections occurred in males in the United States. Three randomized controlled trials demonstrated that male circumcision decreased a man's risk for HIV acquisition through heterosexual sex. We describe circumcision prevalence in US males and determine circumcision prevalence among males potentially at increased risk for heterosexually acquired HIV infection. METHODS: We estimated circumcision prevalence among men and boys aged 14 to 59 years using data from the National Health and Nutrition Examination Surveys 2005-2010. We defined men and boys with 2 or more female partners in the last year as potentially at increased risk for heterosexually acquired HIV infection. RESULTS: Estimated circumcision prevalence was 80.5%. Prevalence varied significantly by year of birth, race/ethnicity, health insurance type, and family income. Circumcision prevalence among men and boys reporting 2 or more female partners in the last year was 80.4%, which corresponded to an estimated 3.5 million uncircumcised men and boys potentially at increased risk for heterosexually acquired HIV infection. Of these men and boys, 48.3% lacked health insurance. CONCLUSIONS: Circumcision prevalence in the United States differs by demographic group, and half of uncircumcised men and boys potentially at increased risk for heterosexually acquired HIV are uninsured. These data could inform recommendations and cost analyses concerning circumcision in the United States.

Challenges in congenital syphilis surveillance: how are congenital syphilis investigations classified?

BACKGROUND: Congenital syphilis is a serious, preventable, and nationally notifiable disease. Despite the existence of a surveillance case definition, congenital syphilis is sometimes classified differently using an algorithm on the Centers for Disease Control and Prevention's case reporting form. METHODS: We reviewed Louisiana's congenital syphilis electronic reporting system for investigations of infants born from January 2010 to October 2011, abstracted data required for classification, and applied the surveillance definition and the algorithm. We calculated the sensitivities and specificities of the algorithm and Louisiana's classification using the surveillance definition as the surveillance gold standard. RESULTS: Among 349 congenital syphilis investigations, the surveillance definition identified 62 cases. The algorithm had a sensitivity of 91.9% and a specificity of 64.1%. Louisiana's classification had a sensitivity of 50% and a specificity of 91.3% compared with the surveillance definition. CONCLUSIONS: The differences between the algorithm and the surveillance definition led to misclassification of congenital syphilis cases. The algorithm should match the surveillance definition. Other state and local health departments should assure that their reported cases meet the surveillance definition.

Hospitalization cost of congenital syphilis diagnosis from insurance claims data in the United States.

We analyzed medical insurance claims data (2005-2009) to determine the hospitalization costs of newborns with congenital syphilis (CS) diagnoses. We found 44 admission claims with CS diagnosis. The excess cost per case of CS (in 2009 US dollars) was estimated at $9969 (95% confidence interval, $5702-$16,769).

Improvement in peripheral blood disease burden in patients with Sézary syndrome and leukemic mycosis fungoides after total skin electron beam therapy.

BACKGROUND: There is a paucity of effective therapies for patients with Sézary syndrome and advanced mycosis fungoides with peripheral blood involvement. Total skin electron beam (TSEB) radiation therapy is an extremely effective skin-directed therapy for these patients, but, until recently, it was thought not to signifcantly affect the peripheral blood malignant T-cell population. OBJECTIVE: We conducted this study to determine if TSEB has therapeutic effect on the peripheral blood in patients with advanced mycosis fungoides and Sézary syndrome. METHODS: All patients on stable medication regimens seen in our photopheresis facility who received TSEB therapy between January 2008 and October 2011 at Temple University Hospital, Philadelphia, PA, were analyzed retrospectively for improvement in the peripheral blood, as documented by flow cytometry. RESULTS: Six of 11 patients achieved 50% or greater decrease in their peripheral blood malignant T-cell population after TSEB therapy, for an overall response rate of 55%. Within the group of patients who had a response in the skin, 67% also had a response in the peripheral blood. LIMITATIONS: This analysis is limited in 3 ways. First, the sample described is small. Second, the results may be confounded by the fact that each patient was on other systemic therapies in addition to TSEB, albeit stable pre-existing regimens. The time interval between completion of TSEB therapy and repetition of flow cytometry was not standardized among patients, which may result in an underestimation of the overall response to TSEB therapy. CONCLUSION: In patients with advanced mycosis fungoides and Sézary syndrome, the peripheral blood tumor burden may improve after treatment with TSEB.

High clinical response rate of Sezary syndrome to immunomodulatory therapies: prognostic markers of response.

OBJECTIVES: To quantify response rates of Sézary syndrome (SS) to multimodality immunomodulatory therapy and to identify the important prognostic parameters that affect overall response to treatment. DESIGN: Retrospective cohort study. SETTING: Cutaneous T-cell lymphoma clinic at The Hospital at the University of Pennsylvania. PARTICIPANTS: Ninety-eight patients who met the revised International Society for Cutaneous Lymphomas (ISCL) and the European Organization of Research and Treatment of Cancer (EORTC) criteria for the diagnosis of SS and were seen over a 25-year period at the University of Pennsylvania. Intervention Patients were treated with at least 3 months of extracorporeal photopheresis and 1 or more systemic immunostimulatory agents. MAIN OUTCOME MEASURES: Overall response to treatment was the main measurement of outcome. RESULTS: A total of 73 patients had significant improvement with multimodality therapy: 30% had complete response, with clearing of all disease (n = 29), and 45% had partial response (n = 44). At baseline, the complete response group had a lower CD4/CD8 ratio than the nonresponse group (13.2 vs 44.2) (P = .04) and a lower median percentage of CD4(+)/CD26(-) cells (27.4% vs 57.2%) (P = .01) and CD4(+)/CD7(-) cells (20.0% vs 41.3%) (P < .01). Median monocyte percentage at baseline was higher for patients who had a complete response than for nonresponders (9.5% vs 7.3%) (P = .02). The partial response group did not have any statistically significant variables compared with the nonresponse group. CONCLUSIONS: In this large cohort study of patients with SS, a high clinical response rate was achieved using multiple immunomodulatory therapies. A lower CD4/CD8 ratio, a higher percentage of monocytes, and lower numbers of circulating abnormal T cells at baseline were the strongest predictive factors for complete response compared with nonresponse and warrant further examination in a larger cohort.