Clindamycin-induced acute generalized exanthematous pustulosis: A case report.

RATIONALE: Acute generalized exanthematous pustulosis (AGEP) is a severe pustular cutaneous adverse drug reaction. Sterile, non-follicular pustules overlying the erythematous skin characterize this reaction. PATIENT CONCERNS: A 30-year-old Asian women presented with sterile, non-follicular lesions with pus-fluid levels on her back 2 days after taking clindamycin. Skin biopsy revealed a spongiotic change in the epidermis with a focal subcorneal pustule and perivascular eosinophil and lymphocyte infiltration. DIAGNOSIS: Clindamycin-induced AGEP. INTERVENTIONS: We discontinued clindamycin treatment and prescribed systemic corticosteroids. OUTCOMES: The pustule stopped spreading within 1 day and the rash improved within 2 days. LESSONS: AGEP is a pustular cutaneous adverse drug reaction that can appear with pus-fluid levels, clinically mimicking Sneddon-Wilkinson disease. The differentiation between both conditions is a history of drug use, characteristic skin lesions and histopathology.

Burkitt lymphoma initially mimicking varicella zoster infection.

Burkitt lymphoma is an aggressive type of nodal non-Hodgkin lymphoma. This disease commonly involves the gastrointestinal tract, bone marrow, central nervous system, and in rare instances, the skin. We report the case of a 78-year-old Asian man who had experienced subacute fever and significant weight loss. He initially presented with a zosteriform skin rash on his right temporal area, which primary physicians diagnosed as varicella zoster infection and treated with antiviral drugs. The rash developed on the left forehead and chest. Dermatopathological studies on a skin lesion on the chest wall showed characteristics of Burkitt lymphoma. After a week of palliative chemotherapy, regression of all skin lesions was observed. This report aims to demonstrate an unusual zosteriform pattern of cutaneous involvement in Burkitt lymphoma.

Thrombotic thrombocytopenic purpura and hemophagocytic lymphohistiocytosis in an elderly man: A case report.

RATIONALE: Thrombotic thrombocytopenic purpura (TTP) and hemophagocytic lymphohistiocytosis (HLH) are rare hematologic conditions and have high mortality. Both TTP and HLH result from deregulation of the immune system. There are no published reports of coexisting TTP and HLH in elderly patients. PATIENT CONCERNS: A 67-year-old Asian male presented with altered consciousness and fever for 2 days. Physical examination revealed markedly pale, mild icterus with petechiae and purpura. Initially, TTP was recognized in this patient. Bone marrow studies are suggested for evaluating elderly patients to assess specific causes, especially infection and neoplasm. DIAGNOSES: The TTP was diagnosed based on typical history-related symptoms and a specific laboratory result of very low ADAMTS13 level. The diagnosis of HLH was determined after detection of high levels of ferritin and lactase dehydrogenase, which were confirmed by the presence of hemophagocytosis in the bone marrow. INTERVENTIONS: Systemic corticosteroids and plasma exchange were initiated as specific treatment of the patient. OUTCOMES: The patient died in 3 weeks from ventilator-associated pneumonia. LESSONS: The HLH should be tested using bone marrow studies and specific laboratory tests in patients with TTP.

Risk Factors for Invasive Fungal Infection among Thai Oncologic Patients with Febrile Neutropenia and Cutaneous Presentation: A 5-Year Retrospective Study in Southern Thailand

Background: Febrile neutropenia (FNP) is a condition defined by fever and neutropenia. There are current only limited data on related cutaneous manifestations. This study aimed to assess cutaneous lesions and their etiologies in a Thai group of FNP patients. Methods: A retrospective analysis was conducted on 43 non-transplant febrile neutropenic patients with concurrent cutaneous lesions, as determined by dermatopathologic studies at Songklanagarind Hospital in Thailand over a five-year period. Results: The mean age was 39 years (SD: 18.8). Approximately 60% were male. The most common underlying disease was a hematologic neoplasm. Twenty-one of the participants had developed FNP within 7.5±8.7 days after presenting with skin lesions. Twenty-two participants had skin lesions 9.0±11.1 days after FNP diagnosis. Cutaneous manifestations were mostly in the form of multiple lesions (67.4%), of which the most common were nodular skin lesions (37.2%) presenting on the lower extremities of the body (58.1%). The dermatopathologic diagnoses included infections which were almost all fungal and leukemia cutis. The development of skin lesions after FNP proved to be a statistically significant risk factor for fungal infection (OR 8.13, P = 0.009), whereas age (over 40 years) proved to be a statistically significant protective factor (OR 0.20, P = 0.04). Conclusions: There are a variety of cutaneous manifestations in FNP, of which the most common were cutaneous nodular skin lesions in the lower extremities. The most frequent infection was fungal in patients under 40 who had developed skin lesions after FNP.

Erythema multiforme-like cutaneous lesions in monomorphic epitheliotropic intestinal T-cell lymphoma: a rare case report.

Monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL), also known as Type II enteropathy-associated T-cell lymphoma (EATL), is an aggressive peripheral T-cell lymphoma. EATL generally presents in adults with gastrointestinal symptoms. Skin involvement is very rare, found only in approximately five percent of patients. The authors report a 67-year-old Asian male who presented with chronic diarrhea and developed erythema multiforme-like cutaneous lesions. A skin biopsy revealed extensive pagetoid spread of atypical lymphocytes in the epidermis. The results of an immunohistochemistry test led to a diagnosis of MEITL. This report points to the need for dermatologists and dermatopathologists to consider a possible diagnosis of MEITL when encountering similar cases.

Incidence, etiology and bone marrow characteristics of non-chemotherapy-induced agranulocytosis.

OBJECTIVE: Agranulocytosis is a rare but fatal condition. The majority of cases are associated with drugs. However, in-patient incidences and the relationship between clinical outcomes and bone marrow characteristics have not been established. METHODS: We conducted a retrospective study in a university hospital. A total of 38 in-patients diagnosed with agranulocytosis were analyzed. RESULTS: The average incidence of agranulocytosis in Songklanagarind Hospital between 1993 and 2007 was 0·98 cases per 10 000 admissions per year. Antimicrobial agents were the most common etiology (63% of patients) and antithyroid agents were the second most common (13·6%). Two patterns of bone marrow were noted: type I was characterized by a left-shifted granulopoiesis and type II was recognized as having hypocellular bone marrow with markedly reduced granulocyte precursors. A significantly higher mortality was associated with type II. CONCLUSION: Antimicrobial agents are the most common cause and the rare granulocyte precursors in bone marrow are associated with higher mortality rates.