treatment of subcutaneous mycoses in, International Symposium on Mycoses. Pan American Health Organization, Scientific Publication No. 205. Washington, DC, World Health Organization, 1970, pp 123-127.
Nocardia brasiliensis
Mycetoma: Treatment With Co-trimoxazole To the Editor.\p=m-\A recent study documents the efficacy of dapsone in the treatment of Nocardia asteroides mycetoma.1 Reference was made to successful treatment of Nocardia mycetoma with cotrimoxazole (Bactrim or Septrin), a combination of 80 mg of trimethoprim and 400 mg of sulfamethoxazole, which acts synergetically.
Our case report and accompanying references suggest that co-trimoxazole might be a treatment of choice in N brasiliensis mycetoma.
Report of a Case.\p=m-\A49-year-old woman stepped on a rusty nail while vacationing in Hawaii in 1970. The nail was thought to have penetrated to a depth of approximately 1 cm. The lesion promptly healed. In July 1973, she noted two painful red nodules on
the distal surface of the same foot. Her family physician prescribed 500\x=req-\ mg ampicillin capsules four times per day for three weeks, and then 250-mg tetracycline capsules four times per day for five days. By September, the nodules started to drain. Biopsy showed granulation tissue with a dense subacute inflammatory infiltrate; N brasiliensis grew in culture. Therapy with daily adminis¬ tration of co-trimoxazole tablets was instituted with complete involution of lesions in ten weeks. Comment.-González-Ochoa and Tamayo and Mahgoub should be consult¬ ed for details of other similarly treated patients.2"4 Howard I. Maibach, MD William Gorham, MD Raza Aly, PhD San Francisco References Rogers RS III, Muller SA: Treatment of actinomycetoma with dapsone: A report of infec1.
tion with Nocardia asteroides. Arch Dermatol 109:529-534, 1974. 2. Gonz\l=a'\lez-OchoaA, Tamayo L: Tratamiento del micetoma actinomicetico por N. brasiliensis con Ro-2580/11. Med Rev Mex 49:473-476, 1969. 3. Mahgoub, ES: Treatment of actinomycetoma with sulphamethoxazole plus trimethoprim. Am J Trop Med Hyg 21:332-335, 1972. 4. Gonz\l=a'\lez-Ochoa A: The prevention and
Kaposi Sarcoma To the Editor.\p=m-\In a recent paper in the Archives on Kaposi sarcoma (110:602, 1974), Klein et al report the case of a 37-year-old woman. She had systemic lupus erythematosus, for which she was being treated with azathioprine and prednisone. Three months after onset of therapy, she suddenly developed four cutaneous nodules on the extremities. They ranged in size from 5 to 15 mm, were dusky brown, and were freely movable. The description and pictorial presentation of the patient's lesions, their color and location, seem to portray the picture of multiple dermatofibromas. This impression seems to be supported by the accompanying photomicrograph and its description in the article showing intertwining collagen bundles composed on monomorphic fibroblasts arranged around dilated vessels with well-outlined endothelium. This picture is different from the "vascular slit" pattern seen in Kaposi sarcoma but suggests a dermatofibroma variant of sclerosing hemangioma. Furthermore, the age, sex, and racial background of the described patient are inconsistent with the visual characteristics of Kaposi sarco¬ ma, as the authors point out. I am suggesting that this patient may have a condition described by Newman and Walter (AT Engl J Med 289:842, 1973) as multiple dermatofi¬ bromas in patients with systemic
lupus erythematosus on immunosuppressive therapy, since six patients
who had many dermatofibromas each were reported by them. LTC Detlef K. Goette, MC, USA LTC Richard B. Odom, MC, USA San Francisco Periorbital Edema
To the Editor.\p=m-\Ina recent Society Transactions of the Archives, a case of periorbital edema was discussed (110:140, 1974). Thyroid disease was briefly considered. We wish to describe a similar case that has proved educational. In November 1971, a 63-year-old woman developed swelling of the eyelids. An ophthalmologist was con-
Downloaded From: http://archderm.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/27/2015
suited, and a topical antibiotic-steroid preparation was prescribed. The condition persisted, and she was seen by
month after onset. The of swelling only, with no other symptoms referable to the eyes. Examination showed definite symmetrical edema of lower and upper eyelids, without signs of inus
about
one
patient complained
flammation. The conjunctivas were normal without redness or swelling, and
exophthalmos
was
not
clinically
apparent. A detailed history and
physical examination revealed only moderate arthritis of the interphalangeal joints of the left thumb and forefinger. There was mild xerosis of the lower extremities. The hands were noted to be spade-like in configuration. There was nothing to suggest hypoproteinemia of hepatic or renal
origin, hypothyroidism or hyperthyroidism, trichinosis, cardiac edema, or dermatomyositis. The patient's condi¬ tion was diagnosed as idiopathic periorbital edema. However, by April of 1972, the patient had developed additional symptoms of increased lacrimation, blurred vision, and burning of the eyes. Chemosis had developed. Signif¬ icant findings included protrusion on
exophthalmometry,
decreased lateral
gaze, deviation of the right eye medially on forward gaze, and an increase in retroorbital resistance bilaterally. Serum T, and T4 values, as well as the radioactive iodine uptake, were within the normal range. How¬ ever, there was absence of radioactive iodine uptake suppression after ad¬
ministration of
liothyronine
sodium
(Cytomel), 75/ig daily, for one week. A diagnosis of euthyroidism with infiltrative exophthalmopathy (euthyroid Graves disease) was made.
Treatment was begun with an abla¬ tive dose of sodium iodide I 131, followed with replacement doses of desiccated thyroid. In May of 1973, her condition was judged as definitely
improved.
It would appear that early euthy¬ roid Graves disease should be consid¬ ered in the differential diagnosis of idiopathic periorbital edema. The usual thyroid panel (T3 and T4 tests, free thyroxin index, and proteinbound iodine) is not enough for the investigation of thyroid function in such cases. Michael Eichwald, MD Redding, Calif Hugh Merhoff, MD Red Bluff, Calif
Nocardia brasiliensis
Mycetoma: Treatment With Co-trimoxazole To the Editor.\p=m-\A recent study documents the efficacy of dapsone in the treatment of Nocardia asteroides mycetoma.1 Reference was made to successful treatment of Nocardia mycetoma with cotrimoxazole (Bactrim or Septrin), a combination of 80 mg of trimethoprim and 400 mg of sulfamethoxazole, which acts synergetically.
Our case report and accompanying references suggest that co-trimoxazole might be a treatment of choice in N brasiliensis mycetoma.
Report of a Case.\p=m-\A49-year-old woman stepped on a rusty nail while vacationing in Hawaii in 1970. The nail was thought to have penetrated to a depth of approximately 1 cm. The lesion promptly healed. In July 1973, she noted two painful red nodules on
the distal surface of the same foot. Her family physician prescribed 500\x=req-\ mg ampicillin capsules four times per day for three weeks, and then 250-mg tetracycline capsules four times per day for five days. By September, the nodules started to drain. Biopsy showed granulation tissue with a dense subacute inflammatory infiltrate; N brasiliensis grew in culture. Therapy with daily adminis¬ tration of co-trimoxazole tablets was instituted with complete involution of lesions in ten weeks. Comment.-González-Ochoa and Tamayo and Mahgoub should be consult¬ ed for details of other similarly treated patients.2"4 Howard I. Maibach, MD William Gorham, MD Raza Aly, PhD San Francisco References Rogers RS III, Muller SA: Treatment of actinomycetoma with dapsone: A report of infec1.
tion with Nocardia asteroides. Arch Dermatol 109:529-534, 1974. 2. Gonz\l=a'\lez-OchoaA, Tamayo L: Tratamiento del micetoma actinomicetico por N. brasiliensis con Ro-2580/11. Med Rev Mex 49:473-476, 1969. 3. Mahgoub, ES: Treatment of actinomycetoma with sulphamethoxazole plus trimethoprim. Am J Trop Med Hyg 21:332-335, 1972. 4. Gonz\l=a'\lez-Ochoa A: The prevention and
Kaposi Sarcoma To the Editor.\p=m-\In a recent paper in the Archives on Kaposi sarcoma (110:602, 1974), Klein et al report the case of a 37-year-old woman. She had systemic lupus erythematosus, for which she was being treated with azathioprine and prednisone. Three months after onset of therapy, she suddenly developed four cutaneous nodules on the extremities. They ranged in size from 5 to 15 mm, were dusky brown, and were freely movable. The description and pictorial presentation of the patient's lesions, their color and location, seem to portray the picture of multiple dermatofibromas. This impression seems to be supported by the accompanying photomicrograph and its description in the article showing intertwining collagen bundles composed on monomorphic fibroblasts arranged around dilated vessels with well-outlined endothelium. This picture is different from the "vascular slit" pattern seen in Kaposi sarcoma but suggests a dermatofibroma variant of sclerosing hemangioma. Furthermore, the age, sex, and racial background of the described patient are inconsistent with the visual characteristics of Kaposi sarco¬ ma, as the authors point out. I am suggesting that this patient may have a condition described by Newman and Walter (AT Engl J Med 289:842, 1973) as multiple dermatofi¬ bromas in patients with systemic
lupus erythematosus on immunosuppressive therapy, since six patients
who had many dermatofibromas each were reported by them. LTC Detlef K. Goette, MC, USA LTC Richard B. Odom, MC, USA San Francisco Periorbital Edema
To the Editor.\p=m-\Ina recent Society Transactions of the Archives, a case of periorbital edema was discussed (110:140, 1974). Thyroid disease was briefly considered. We wish to describe a similar case that has proved educational. In November 1971, a 63-year-old woman developed swelling of the eyelids. An ophthalmologist was con-
Downloaded From: http://archderm.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/27/2015
suited, and a topical antibiotic-steroid preparation was prescribed. The condition persisted, and she was seen by
month after onset. The of swelling only, with no other symptoms referable to the eyes. Examination showed definite symmetrical edema of lower and upper eyelids, without signs of inus
about
one
patient complained
flammation. The conjunctivas were normal without redness or swelling, and
exophthalmos
was
not
clinically
apparent. A detailed history and
physical examination revealed only moderate arthritis of the interphalangeal joints of the left thumb and forefinger. There was mild xerosis of the lower extremities. The hands were noted to be spade-like in configuration. There was nothing to suggest hypoproteinemia of hepatic or renal
origin, hypothyroidism or hyperthyroidism, trichinosis, cardiac edema, or dermatomyositis. The patient's condi¬ tion was diagnosed as idiopathic periorbital edema. However, by April of 1972, the patient had developed additional symptoms of increased lacrimation, blurred vision, and burning of the eyes. Chemosis had developed. Signif¬ icant findings included protrusion on
exophthalmometry,
decreased lateral
gaze, deviation of the right eye medially on forward gaze, and an increase in retroorbital resistance bilaterally. Serum T, and T4 values, as well as the radioactive iodine uptake, were within the normal range. How¬ ever, there was absence of radioactive iodine uptake suppression after ad¬
ministration of
liothyronine
sodium
(Cytomel), 75/ig daily, for one week. A diagnosis of euthyroidism with infiltrative exophthalmopathy (euthyroid Graves disease) was made.
Treatment was begun with an abla¬ tive dose of sodium iodide I 131, followed with replacement doses of desiccated thyroid. In May of 1973, her condition was judged as definitely
improved.
It would appear that early euthy¬ roid Graves disease should be consid¬ ered in the differential diagnosis of idiopathic periorbital edema. The usual thyroid panel (T3 and T4 tests, free thyroxin index, and proteinbound iodine) is not enough for the investigation of thyroid function in such cases. Michael Eichwald, MD Redding, Calif Hugh Merhoff, MD Red Bluff, Calif
