54 year old man with multiple sores

Presenter: Mike Garone DO, Natalie Steinhoff DO, Jessie Perkins DO
Dermatology Program: NSUCOM/Largo Medical Center
Program Director: Richard Miller, DO, FAOCD
Submitted on: May 27, 2016

CHIEF COMPLAINT:  54 year old man with multiple “sores” on the left hand, chest and right neck.

CLINICAL HISTORY:

Signs and symptoms:  ROS:
(-) fevers/chills/night sweats/unexplained weight loss
(-) nasal congestion or sore throat
(-) epistaxis
(-) mucosal erosions
(-) n/v/d/hematochezia/melena
(-) h/o immunodeficiency or HIV
(+) chest congestion and rhinorrhea qAM (denies history of allergic rhinitis prior to being bit)

PMHx: Hypothyroidism
PSxHx: negative
FamHx: Father with prostate cancer
SocHx: patient is a government contracted pilot who makes frequent visits to the Middle East; social ETOH; denies tobacco/illicit drugs
Meds: Levothyroxine
Allergies: NKDA

Previous Treatment:  Treated by PCP with permethrin as well as triamcinolone 0.1% topical cream. It was later treated with systemic azithromycin and pimecrolimus topical

Other information:  3 months prior, patient states he was working in Iraq, where he was bitten by insects and he states some of the bug bites never healed

PHYSICAL EXAM:

Right Neck

 

Chest

Vital signs: Within normal limits
Constitutional: No acute distress, pleasant
Skin: erythematous nodules with central erosion and crust on the right neck, mid chest, and left hand

LABORATORY TESTS:

CT of the chest, abdomen, pelvis showed degenerative joint disease and prostate enlargement but was otherwise negative.
CBC, CMP within normal limits.
Ultrasound of the left upper extremity showed lymphadenopathy.
Bacterial and fungal culture of the right neck came back negative.
Tissue culture of the left chest also came back negative.
PCR was done by the CBC and positive for the causative organism.

DERMATOHISTOPATHOLOGY:

Histology on scan

 

Parasitized macrophages

Dermal infiltrate composed of lymphocytes with occasional plasma cells. On higher power, there are several parasitized macrophages. The organisms tend to organize at the periphery of the macrophages, the so-called marquee sign.

DIFFERENTIAL DIAGNOSIS:

1.   Histoplasmosis
2.   Leishmaniasis
3.   Sarcoidosis
4.   Sporotrichosis
5.   Granuloma Inguinale


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