Letters to the Editor

REFERENCES 1 Vlachos SP, Kontoes PP. Development of terminal hair following skin lesion treatments with an intense pulsed light source. Aesthetic Plast Surg 2002; 26: 303–307. 2 Alajlan A, Shapiro J, Rivers JK, MacDonald N, Wiggin J, Lui H. Paradoxical hypertrichosis after laser epilation. J Am Acad Dermatol 2005; 53: 85–88.

3 Bernstein EF. Hair growth induced by diode laser treatment. Dermatol Surg 2005; 31: 584–586. 4 Radmanesh M. Paradoxical hypertrichosis and terminal hair change after intense pulsed light hair removal therapy. J Dermatolog Treat 2009; 20: 52–54. 5 Bouzari N, Firooz AR. Lasers may induce terminal hair growth. Dermatol Surg 2006; 32: 460.

Bilateral linear nevus sebaceous: An unusual case Dear Editor, Nevus sebaceous (NS) is a well-known congenital epidermal hamartoma of the skin. The condition is most commonly found on the head and face.1 NS consists of a circumscribed, slightly raised plaque, and usually appears unilaterally. Linearly arranged NS is often accompanied by other systemic abnormalities. Herein, we report a case of bilateral and linear NS on the neck in a young, healthy man. A 19-year-old man presented with multiple asymptomatic skin lesions on the right side of his neck that had been present since birth. Over time, these lesions increased in number and became more prominent and pigmented. During puberty, similar cutaneous lesions appeared on the left side of his neck. He had no previous relevant medical history, including local trauma or surgery. Upon examination, multiple, symmetrical, linearly distributed, flesh-colored and/or brownish small verrucous papules 2–4 mm in diameter were found on both lateral sides of his neck. Crusty areas and erythema as a result of unconscious scratching were present (Fig. 1a,b). Because the lesions had characteristic distribution and verrucous features, it was initially thought that the patient had inflammatory, linear, verrucous, epidermal nevus or verruca vulgaris. The most discrete papules were completely excised to obtain a diagnosis. Each specimen had the same histopathological findings, including hyperkeratosis, acanthosis, prominent papillomatosis in the epidermis and the sebaceous glands, and hyperplasia of the apocrine glands in the dermis (Fig. 1c,d). Finally, the diagnosis of bilateral linear NS was made. We recommended total excision of the remaining lesions, but the patient refused and wanted careful observation of the lesions. The published work review concluded that NS commonly occurs in a single location, rarely on multiple locations.2 One author stated that cases of multiple NS never cross the midline.3 A case of multiple NS located on both sides of the body, although extremely rare, has been reported in the English-language published work. Chi et al.4 described a case of multiple NS occurring on the scalp and the contralateral side of the face. However, interestingly, the NS lesions in our patient occurred symmetrically on both lateral sides of the neck. NS is not usually accompanied by any other abnormalities. When linearly arranged NS is accompanied by other systemic abnormalities, it is called linear NS syndrome. NS syndrome encompasses a

(a)

(b)

(c)

(d)

Figure 1. (a,b) Bilateral, linear, discrete papules on both lateral aspects of the neck. Close-up view shows flesh-colored to brown, verrucous papules. Some papules have crusts and surrounding erythema (insets). (c,d) Acanthosis, hyperkeratosis with marked papillomatosis in the epidermis and sebaceous glands hyperplasia in the dermis. Hyperplastic ectopic apocrine glands in the lower dermis (hematoxylin–eosin, original magnification 940).

broad spectrum of abnormalities that may affect every organ system, including the central nervous system, cardiovascular, skeletal, ophthalmologic and urogenital systems.5

Correspondence: Joong Sun Lee, M.D., Ph.D., Department of Dermatology, Eulji University School of Medicine, Eulji University Hospital, 95 Dunsanseo-ro, Seo-gu, Daejeon 302-799, Korea. Email: [email protected]

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© 2014 Japanese Dermatological Association

Letters to the Editor

In this report, both lesions of the NS were distributed with symmetrical arrangement. In addition, no systemic abnormalities associated with the linear NS syndrome were found in this case. Therefore, this case presents a rare phenotype: sporadic, bilateral, linear NS. It is noted that NS, which is generally known to occur on one side of the body, can rarely occur symmetrically on both sides of the body. Furthermore, when the dermatologist encounters a patient with bilateral linearly distributed verrucous papules or plaques, a skin biopsy should be performed prior to treatment to obtain an accurate diagnosis.

CONFLICT OF INTEREST:

None.

Hye Min LEE, Dae Won KOO, Joong Sun LEE

doi: 10.1111/1346-8138.12646

REFERENCES 1 Eisen DB, Michael DJ. Sebaceous lesions and their associated syndromes. J Am Acad Dermatol 2009; 61: 552–553. 2 Cribier B, Scrivener Y, Grosshans E. Tumors arising in nevus sebaceus: a study of 596 cases. J Am Acad Dermatol 2000; 42: 263–268. 3 Correale D, Ringpfeil F, Rogers M. Large, papillomatous, pedunculated nevus sebaceus: a new phenotype. Pediatr Dermatol 2008; 25: 355–358. 4 Chi SG, Kim JY, Kim HY, Lee SJ, Kim DW, Lee WJ. Multiple nevus sebaceous occurring on the scalp and on the contralateral side of the face. Ann Dermatol 2011; 23: 389–391. 5 Menascu S, Donner EJ. Linear nevus sebaceous syndrome: case reports and review of the literature. Pediatr Neurol 2008; 38: 207– 210.

Department of Dermatology, Eulji University School of Medicine, Eulji University Hospital, Daejeon, Korea

Metastatic tuberculous abscess as a manifestation of miliary tuberculosis Dear Editor, Metastatic tuberculous abscess (MTA) is a form of tuberculosis that arises independently of any apparent adjacent tuberculous focus, and is the result of hematogenous dissemination from a primary focus during periods of bacillemia. A 45-year-old woman was referred to our department because of a painful indurated erythema of the forearm (Fig. 1a) and ulceration of the finger (Fig. 1b). The patient’s father and grandfather had pulmonary tuberculosis. In September 2013, she visited an orthopedist because of multiple episodes of small joint pain of the hands. She was clinically diagnosed as having rheumatoid arthritis (RA) and administration of 10 mg/week methotrexate was commenced in November 2013. The symptoms did not improve, therefore, prednisolone (10 mg) was added in January 2014. After 2 months, the arthralgia still remained and she had respiratory discomfort and difficulty in dietary intake. She was admitted to the Department of Rheumatology of our hospital and referred to our department for her skin lesions. She had a high fever of 39.7°C and severe general malaise. A physical examination revealed that the patient had oral mucosal erosions, painful indurated erythemas in the forearm, and ulcers of the left thumb and right index finger. The results of the laboratory examination were as follows: white blood cell count, 9700/ mm3; C-reactive protein, 24.61 mg/dL; rheumatoid factor (RF), 23 IU/mL; anti-cyclic citrullinated peptide antibodies, less than 0.6 U/mL; and matrix metalloproteinase-3, 78.1 ng/mL. Based on these findings, we suspected septicemia, and performed a skin biopsy from the forearm.

The histopathological examination revealed that the inflammatory cells of lymphocytes and histiocytes infiltrated around the vessels in the subcutaneous fat tissue (Fig. 1c,d). Ziehl– Neelsen staining revealed numerous acid-fast bacilli around the vessel (Fig. 1e). DNA for Mycobacterium tuberculosis was detected in the skin, sputum and gastric juice by polymerase chain reaction amplification. QuantiFERON-TB Gold test was positive. M. tuberculosis was cultured from the skin tissue. Chest X-rays and thoracic computed tomography showed multiple scattered miliary lesions on both lungs. The patient was therefore diagnosed as having MTA complicated with pulmonary miliary tuberculosis. Two months after antituberculosis treatment, the skin lesion and ulcers showed marked improvement, and the patient was discharged. We herein reported a rare case of cutaneous tuberculosis, MTA, in a patient who had been misdiagnosed with RA and unnecessarily administrated methotrexate and corticosteroid. Gu et al.1 previously reported a case of disseminated tuberculosis with finger swelling and a skin ulcer like our case. That patient also had skeletal tuberculosis. Seung and Sulaiman2 reported a rare case of osteoarticular tuberculosis involving multiple small joints of the hands, which mimicked RA. Considering the negative RF findings and the fact that the multiple small joint pain improved after the treatment of the tuberculosis, it is possible that the present patient also had osteoarticular tuberculosis. There have been several reports of patients who had swelling of the fingers, skin ulcers and cellulitis as a result of the hematogenous spread of tuberculosis.1,3–5 MTA should be kept in mind when an immunocompromised patient

Correspondence: Madoka Kato, M.D., Department of Dermatology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan. Email: [email protected]

© 2014 Japanese Dermatological Association

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Bilateral linear nevus sebaceous: an unusual case.

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