Letters to the Editor
1238
lesions and paying more attention to environmental factors to which patients are currently or occasionally exposed.
Acknowledgements We thank Professor F. P. d’Errico from the Department of Entomology and Agrarian Zoology, University of Naples Federico II, Italy, for identifying the larvae. S. Lembo, A. Patrı,* C. Lembo, A. Balato Department of Clinical Medicine and Surgery – Section of Dermatology, University of Naples Federico II, Naples, Italy *Correspondence: A. Patrı. E-mail: [email protected]
References 1 House HR, Ehlers JP. Travel-related infections. Emerg Med Clin North Am 2008; 26: 499–516. 2 Palmieri JR, North D, Santo A. Furuncular myiasis of the foot caused by the tumbu fly, Cordylobia anthropophaga: report in a medical student returning from a medical mission trip to Tanzania. Int Med Case Rep J 2013; 6: 25–28. 3 Calderaro A, Peruzzi S, Gorrini C et al. Myiasis of the scalp due to Dermatobia hominis in a traveller returning from Brazil. Diagn Microbiol Infect Dis 2008; 60: 417–418. 4 Varani S, Tassinari D, Elleri D et al. A case of furuncular myiasis associated with systemic inflammation. Parasitol Int 2007; 56: 330–333. 5 Veraldi S, Gorani A, S€ uss L, Tadini G. Cutaneous myiasis caused by Dermatobia hominis. Pediatr Dermatol 1998; 15: 116–118. 6 Veraldi S, Francia C, Persico MC, La Vela V. Cutaneous myiasis caused by Dermatobia hominis acquired in Jamaica. West Indian Med J 2009; 58: 614–616. 7 Bongiorno MR, Pistone G, Aric o M. Myiasis with Dermatobia hominis in a Sicilian traveller returning from Peru. Travel Med Infect Dis 2007; 5: 196–198. 8 Garavelli PL, Rocchetti A. Dermatobia hominis myiasis: apropos of an imported case. Recenti Prog Med 1999; 90: 629. 9 Guidi B, Olivetti G, Sbordoni G, Garcovich A. Guess what! Diagnosis: cutaneous myiasis due to Dermatobia hominis. Eur J Dermatol 2001; 11: 259–260. 10 Caumes E, Carriere J, Guermonprez G, Bricaire F, Danis M, Gentilini M. Dermatoses associated with travel to tropical countries: a prospective study of the diagnosis and management of 269 patients presenting to a tropical disease unit. Clin Infect Dis 1995; 20: 542–548. 11 Rossi MA, Zucoloto S. Fatal cerebral myiasis caused by the tropical warble fly, Dermatobia hominis. Am J Trop Med Hyg 1973; 22: 267–269.
usually seen in persons over 50 years old, and has a 3:1 male– female ratio.2 The proteins can deposit in numerous tissues and cause organ dysfunction if not halted by therapy. Petechiae, purpura and ecchymoses are the most common skin lesions which can be found in about 15–20% of patients.3 Papular, nodules and plaques are seen as relatively uncommon form of cutaneous manifestations presented as waxy, smooth, and shiny.4 Although tissue deposits can occur in many organs, including heart, lung, liver, spleen, gastrointestinal tract and urinary bladder,5 amyloidosis of scrotum with evidence of systemic amyloidosis is an extremely rare presentation. Here, we describe a case presenting with multiorgan involvement who had skin involvement in the initial stage, followed by progressive oedema in the lower extremities, oedema of scrotum and finally multiorgan dysfunction. A 63-year-old male presented with multiple skin lesions on the face, neck and trunk of 4-year duration, including purpura, petechiae, ecchymoses and papules, such lesions typically occurred even worse after trauma (Fig. 1). He stated progressive oedema in lower extremities and voice hoarse along with dysphagia 2 years ago. He also noticed increased size of the tongue accompanied with recent complaints of oedema in scrotum. The patient had tried many topical medicine but without improvement. Physical examination revealed macroglossia with purulent secretion and the lateral aspects showed indentations from the teeth. Both legs had oedema with positive impression and oedema in scrotum was also obvious. Multiple dark purplish petechiae were spread all over the patient’s face, neck, trunk and limbs, purpura and ecchymosis were also observed. Especially
DOI: 10.1111/jdv.12463
A rare case of primary systemic amyloidosis presenting with multiorgan involvement Editor Primary systemic amyloidosis (PSA), characterized by the pathological production of fibrillar proteins is a rare plasma cell dyscrasia with an incidence of 4.5 per 100 000.1 The condition is
JEADV 2015, 29, 1235–1247
Figure 1 Significant skin manifestations.
© 2014 European Academy of Dermatology and Venereology
Letters to the editor
1239
measurements and additional examination especially the cardiac parameter, we identify that the patient with the highest risk of early mortality. Until we reported this case, at least 13 months after the initial diagnosis, the patient was still alive without treatment, but presented with generalized oedema and poor condition. T. Tian, X.-G. Xu, Y.-H. Li, X.-Y. Liu, H. Guo, B. Li, J.-H. Li* Department of Dermatology, No.1 Hospital of China Medical University, Shenyang, China *Correspondence: J.-H. Li. E-mail: [email protected]
References
Figure 2 Amorphic acidophilic material in the deep dermis, H&E 9 100.
the periorbital skin, the rashes presented as waxy, translucent or purpuric papules, nodules and plaques. Laboratory tests: serum albumin 27.3 g/L (40–55); urine analysis, protein1+; Bence Jones proteinuria, weak positive; Quantitative immunoglobulins, IgA 25 g/L (0.82–4.53) and IgM 0.45 g/L (0.46–3.04); Serum protein electrophoresis, albumin 41.5% (46.6–62.6), c-globulin 34.8% (11.6–24.4); Serum immunofixation, light chain amyloid with Kappa and Lambda were positive. Additional examination: Cardiac ultrasonography showed expansion of both atrium, LADi (Left atrial diameter)39 (50 9 44) mm/m2. The left ventricle was thickened and there was an enhanced myocardial echo. Aortic valve had degenerative diseases. A small area of pericardial effusion was found, and the sonogram showed a dark liquid area. Scrotum ultrasonography revealed that the scrotal wall was thickened with the depth of 2.15 cm, and there was an enhanced strip echo. A dark liquid area could be found in the scrotum, which suggested a small area of biateral hydrocoele effusion. Bone marrow aspirate and biopsy revealed plasmacytosis of 12% (
1238
lesions and paying more attention to environmental factors to which patients are currently or occasionally exposed.
Acknowledgements We thank Professor F. P. d’Errico from the Department of Entomology and Agrarian Zoology, University of Naples Federico II, Italy, for identifying the larvae. S. Lembo, A. Patrı,* C. Lembo, A. Balato Department of Clinical Medicine and Surgery – Section of Dermatology, University of Naples Federico II, Naples, Italy *Correspondence: A. Patrı. E-mail: [email protected]
References 1 House HR, Ehlers JP. Travel-related infections. Emerg Med Clin North Am 2008; 26: 499–516. 2 Palmieri JR, North D, Santo A. Furuncular myiasis of the foot caused by the tumbu fly, Cordylobia anthropophaga: report in a medical student returning from a medical mission trip to Tanzania. Int Med Case Rep J 2013; 6: 25–28. 3 Calderaro A, Peruzzi S, Gorrini C et al. Myiasis of the scalp due to Dermatobia hominis in a traveller returning from Brazil. Diagn Microbiol Infect Dis 2008; 60: 417–418. 4 Varani S, Tassinari D, Elleri D et al. A case of furuncular myiasis associated with systemic inflammation. Parasitol Int 2007; 56: 330–333. 5 Veraldi S, Gorani A, S€ uss L, Tadini G. Cutaneous myiasis caused by Dermatobia hominis. Pediatr Dermatol 1998; 15: 116–118. 6 Veraldi S, Francia C, Persico MC, La Vela V. Cutaneous myiasis caused by Dermatobia hominis acquired in Jamaica. West Indian Med J 2009; 58: 614–616. 7 Bongiorno MR, Pistone G, Aric o M. Myiasis with Dermatobia hominis in a Sicilian traveller returning from Peru. Travel Med Infect Dis 2007; 5: 196–198. 8 Garavelli PL, Rocchetti A. Dermatobia hominis myiasis: apropos of an imported case. Recenti Prog Med 1999; 90: 629. 9 Guidi B, Olivetti G, Sbordoni G, Garcovich A. Guess what! Diagnosis: cutaneous myiasis due to Dermatobia hominis. Eur J Dermatol 2001; 11: 259–260. 10 Caumes E, Carriere J, Guermonprez G, Bricaire F, Danis M, Gentilini M. Dermatoses associated with travel to tropical countries: a prospective study of the diagnosis and management of 269 patients presenting to a tropical disease unit. Clin Infect Dis 1995; 20: 542–548. 11 Rossi MA, Zucoloto S. Fatal cerebral myiasis caused by the tropical warble fly, Dermatobia hominis. Am J Trop Med Hyg 1973; 22: 267–269.
usually seen in persons over 50 years old, and has a 3:1 male– female ratio.2 The proteins can deposit in numerous tissues and cause organ dysfunction if not halted by therapy. Petechiae, purpura and ecchymoses are the most common skin lesions which can be found in about 15–20% of patients.3 Papular, nodules and plaques are seen as relatively uncommon form of cutaneous manifestations presented as waxy, smooth, and shiny.4 Although tissue deposits can occur in many organs, including heart, lung, liver, spleen, gastrointestinal tract and urinary bladder,5 amyloidosis of scrotum with evidence of systemic amyloidosis is an extremely rare presentation. Here, we describe a case presenting with multiorgan involvement who had skin involvement in the initial stage, followed by progressive oedema in the lower extremities, oedema of scrotum and finally multiorgan dysfunction. A 63-year-old male presented with multiple skin lesions on the face, neck and trunk of 4-year duration, including purpura, petechiae, ecchymoses and papules, such lesions typically occurred even worse after trauma (Fig. 1). He stated progressive oedema in lower extremities and voice hoarse along with dysphagia 2 years ago. He also noticed increased size of the tongue accompanied with recent complaints of oedema in scrotum. The patient had tried many topical medicine but without improvement. Physical examination revealed macroglossia with purulent secretion and the lateral aspects showed indentations from the teeth. Both legs had oedema with positive impression and oedema in scrotum was also obvious. Multiple dark purplish petechiae were spread all over the patient’s face, neck, trunk and limbs, purpura and ecchymosis were also observed. Especially
DOI: 10.1111/jdv.12463
A rare case of primary systemic amyloidosis presenting with multiorgan involvement Editor Primary systemic amyloidosis (PSA), characterized by the pathological production of fibrillar proteins is a rare plasma cell dyscrasia with an incidence of 4.5 per 100 000.1 The condition is
JEADV 2015, 29, 1235–1247
Figure 1 Significant skin manifestations.
© 2014 European Academy of Dermatology and Venereology
Letters to the editor
1239
measurements and additional examination especially the cardiac parameter, we identify that the patient with the highest risk of early mortality. Until we reported this case, at least 13 months after the initial diagnosis, the patient was still alive without treatment, but presented with generalized oedema and poor condition. T. Tian, X.-G. Xu, Y.-H. Li, X.-Y. Liu, H. Guo, B. Li, J.-H. Li* Department of Dermatology, No.1 Hospital of China Medical University, Shenyang, China *Correspondence: J.-H. Li. E-mail: [email protected]
References
Figure 2 Amorphic acidophilic material in the deep dermis, H&E 9 100.
the periorbital skin, the rashes presented as waxy, translucent or purpuric papules, nodules and plaques. Laboratory tests: serum albumin 27.3 g/L (40–55); urine analysis, protein1+; Bence Jones proteinuria, weak positive; Quantitative immunoglobulins, IgA 25 g/L (0.82–4.53) and IgM 0.45 g/L (0.46–3.04); Serum protein electrophoresis, albumin 41.5% (46.6–62.6), c-globulin 34.8% (11.6–24.4); Serum immunofixation, light chain amyloid with Kappa and Lambda were positive. Additional examination: Cardiac ultrasonography showed expansion of both atrium, LADi (Left atrial diameter)39 (50 9 44) mm/m2. The left ventricle was thickened and there was an enhanced myocardial echo. Aortic valve had degenerative diseases. A small area of pericardial effusion was found, and the sonogram showed a dark liquid area. Scrotum ultrasonography revealed that the scrotal wall was thickened with the depth of 2.15 cm, and there was an enhanced strip echo. A dark liquid area could be found in the scrotum, which suggested a small area of biateral hydrocoele effusion. Bone marrow aspirate and biopsy revealed plasmacytosis of 12% (
