Blastomycosis-like pyoderma: Report of a case and discussion
Sheinin R, Luther C, Kerr H. Blastomycosis-like pyoderma: Report of a case and discussion. J Am Acad Dermatol 2018; 79(3 Suppl 1):AB58.
J Am Acad Dermatol
Background: Blastomycosis-like pyoderma (BMLP) is a rare condition characterized by vegetative lesions in immunocompromised patients.
Case report: A 60-year-old previously healthy Asian man presented with a 6-month history of painful, malodorous ulcers on his trunk and extremities. Clinically, on the chest, back, and arms there were large round verrucous plaques studded with milia, pustules, and erosions with edematous red borders. His labs were notable for a decreased hemoglobin of 9 g/dL. Tissue culture was positive for methicillin sensitive Staphylococcus aureus. Histology depicted acanthosis, diffuse neutrophilic inflammation, and abscesses. He was diagnosed with BMLP. He failed treatment with prednisone, cyclosporine, and five cycles of IVIg. Sulfamethoxazole-trimethoprim was given with resolution of superinfection. The patient was then started on acitretin while continuing prednisone, cyclosporine, IVIg, and wound care which resulted in improvement of his BMLP. He was later diagnosed with myelodysplastic syndrome via bone marrow biopsy, completed two cycles of azacitidine chemotherapy with further improvement of his BMLP, and plans for bone marrow transplant.
Discussion: BMLP is a rare type of pyoderma that occurs in immunocompromised patients as an exaggerated immune response to bacterial infection, most commonly Staphylococcus aureus. It is characterized by large verrucous plaques with pustules and a raised border. Criteria for diagnosis of BMLP include the following: large verrucous plaques with multiple pustules and elevated border, pseudoepitheliomatous hyperplasia with abscesses on histology, and growth of at least one pathogenic bacteria on tissue culture. Other significant histopathologic findings of BMLP include chronic and granulomatous inflammation, suppurative inflammation, transepidermal elimination, and scarring. BMLP has been treated with oral antibiotics, intralesional steroids, CO2 laser, excision, cryotherapy, and curettage with variable results. Recently, acitretin has been used successfully to treat BMLP, especially in those patients who failed previous antibiotic treatment. The efficacy of acitretin is likely due to its antiproliferative and antiinflammatory properties.
Conclusion: Herein, we presented a case of BMLP successfully treated with acitretin in a patient with underlying myelodysplastic syndrome. It is important to appreciate the widening spectrum of this disease, since BMLP can be the presenting sign of an occult malignancy.
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