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
1117
Letters to the Editor
(a)
(b)
(c)
(d)
(e)
Figure 1. Clinical manifestations at the patient’s first visit. (a) Several indurated erythemas in the forearm. (b) Skin ulcer with black necrosis of the right index finger. (c) Results of the histopathological examination of the lesion in the forearm. Cell infiltration around the vessels in the deep dermis was apparent (hematoxylin–eosin [HE], original magnification 940). (d) High-power magnification revealed that there was infiltration of lymphocytes and histiocytes around the vessels in the deep dermis. (HE, 9400). (e) Numerous acid-fast bacilli were apparent in the dermis (Ziehl–Neelsen, 91000).
presents with indurated erythema or recalcitrant skin ulcers along with general malaise.
CONFLICT OF INTEREST:
The authors have no conflict of
interest to declare.
Madoka KATO, Akira SHIMIZU, Osamu ISHIKAWA Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan doi: 10.1111/1346-8138.12662
1118
REFERENCES 1 Gu JH. Disseminated tuberculosis presenting with finger swelling and skin ulcer: a case report. Int Wound J 2014. doi: 10.1111/iwj.12263. 2 Seung OP, Sulaiman W. Osteoarticular tuberculosis mimicking rheumatoid arthritis. Mod Rheumatol 2012; 22: 931–933. 3 Lee NH, Choi EH, Lee WS, Ahn SK. Tuberculous cellulitis. Clin Exp Dermatol 2000; 25: 222–223. 4 Seyahi N, Apaydin S, Kahveci A, Mert A, Sariyar M, Erek E. Cellulitis as a manifestation of miliary tuberculosis in a renal transplant recipient. Transpl Infect Dis 2005; 7: 80–85. 5 Kim JE, Ko JY, Bae SC, Ro YS. Tuberculous cellulitis as a manifestation of miliary tuberculosis in a patient with malignancy-associated dermatomyositis. J Am Acad Dermatol 2011; 65: 450–452.
© 2014 Japanese Dermatological Association
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
1117
Letters to the Editor
(a)
(b)
(c)
(d)
(e)
Figure 1. Clinical manifestations at the patient’s first visit. (a) Several indurated erythemas in the forearm. (b) Skin ulcer with black necrosis of the right index finger. (c) Results of the histopathological examination of the lesion in the forearm. Cell infiltration around the vessels in the deep dermis was apparent (hematoxylin–eosin [HE], original magnification 940). (d) High-power magnification revealed that there was infiltration of lymphocytes and histiocytes around the vessels in the deep dermis. (HE, 9400). (e) Numerous acid-fast bacilli were apparent in the dermis (Ziehl–Neelsen, 91000).
presents with indurated erythema or recalcitrant skin ulcers along with general malaise.
CONFLICT OF INTEREST:
The authors have no conflict of
interest to declare.
Madoka KATO, Akira SHIMIZU, Osamu ISHIKAWA Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan doi: 10.1111/1346-8138.12662
1118
REFERENCES 1 Gu JH. Disseminated tuberculosis presenting with finger swelling and skin ulcer: a case report. Int Wound J 2014. doi: 10.1111/iwj.12263. 2 Seung OP, Sulaiman W. Osteoarticular tuberculosis mimicking rheumatoid arthritis. Mod Rheumatol 2012; 22: 931–933. 3 Lee NH, Choi EH, Lee WS, Ahn SK. Tuberculous cellulitis. Clin Exp Dermatol 2000; 25: 222–223. 4 Seyahi N, Apaydin S, Kahveci A, Mert A, Sariyar M, Erek E. Cellulitis as a manifestation of miliary tuberculosis in a renal transplant recipient. Transpl Infect Dis 2005; 7: 80–85. 5 Kim JE, Ko JY, Bae SC, Ro YS. Tuberculous cellulitis as a manifestation of miliary tuberculosis in a patient with malignancy-associated dermatomyositis. J Am Acad Dermatol 2011; 65: 450–452.
© 2014 Japanese Dermatological Association
