Disseminated Papules

Presenter: Igor Chaplik, D.O., Charles Gropper, M.D., Cindy Hoffman, D.O.
Dermatology Program: St. Barnabas Hospital Dermatology Department, Bronx, New York
Program Director: Cindy Hoffman, D.O.
Submitted on: Aug 31, 2003

CHIEF COMPLAINT:  Fever, cough, intermittent headaches, weakness, shortness of breath, and a twenty-pound weight loss over the last month.

PHYSICAL EXAM:

The physical exam revealed a cachectic, febrile patient with a temperature of 102.4 F. He was breathing rapidly at 18 breaths per minute, and his heart rate was 76. His blood pressure was 90/66. His skin exam revealed several, discrete, dome-shaped, some umbilicated, papules on the abdomen and chest. Also present were several, hyperpigmented, scaly plaques on his abdomen and chest. (Fig. 1 and 2). Bilateral inguinal and axillary lymph nodes were palpable. Auscultation of the lungs revealed bilateral rales and rhonchi.

Fig. 1 showing numerous, discrete, dome-shaped, some umbilicated papules and several, fairly well-defined, hyperpigmented, scaly plaques on abdomen and chest

 

Fig. 2 Close-up of umbilicated papule

LABORATORY TESTS:

The patient’s complete blood count revealed a white count of 8600, with 84.9% neutrophils. His hemoglobin was low at 10.2 g/dl and his hematocrit low at 31.1%. The patient was found to be HIV positive, with a CD4<20 cells microliter and an rna by pcr of 69965 copies ml/

DERMATOHISTOPATHOLOGY:

His skin biopsy revealed numerous organisms of various sizes surrounded by capsules, which stained positive with mucicarmine in the superficial and deep dermis, with very little inflammatory response. (Fig 3,4)

Fig3. H & E stain of 3mm punch biopsy at 10X showing numerous encapsulated organisms in the superficial and deep dermis with very little inflammatory response

 

Fig. 4. Mucicarmine stain of 3mm punch biopsy at 40X showing the characteristic red staining capsule in the superficial dermis

DIFFERENTIAL DIAGNOSIS:

1.   Coccidioides imitis
2.   Penicillium marneffei
3.   Cryptococcus neoformans
4.   Histoplasma capsulatum
5.   Tuberculosis


Leave a Reply

Your email address will not be published. Required fields are marked *