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عبد الرحمن 10 years old boy complaining of two painful erythematous skin nodules on his chest wall appeared one and a half year ago.
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بس هي بقى لها سنه ونص يعني ظاهره
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not associated with axillary swelling or any other swelling.
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عملنا له biopsy من 6 شهور وطلع فيه scar
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Another nodule appeared on lower abdomen. Condition wasn't associated with fever. Patient generally looks healthy, good built.
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بس هو ده اللي احنا عملناه في الاول
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Lower abdomen skin nodule changed to a black eschar on a red plaque then disappeared totally.
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His back also showed macular rashes which disappeared spontaneously.
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بعد كده عملنا له بقى ال investigations done according to the biopsy result.
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The patient has already done tuberculin test which was negative and CT chest which was also normal at chest hospital.
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then was referred to us. BCG scar not found.
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طبعا انا يعني حولت اخش في ال diagnosis of lupus vulgaris
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فحاولت اطبق عليه ال investigations بتاعته
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Is it Lupus Vulgaris?
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Lupus vulgaris is a chronic and progressive form of cutaneous tuberculosis that represents a reactivation of infection in people with moderate to high immunity against the bacillus.
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It may occur either as a result of direct extension from an underlying focus or via lymphatic or hematogenous spread.
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Without therapy, lesions of lupus vulgaris persist for years, and the plaques may grow to enormous sizes.
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In addition, ulceration and destruction of underlying tissues may occur, causing severe disfigurement.
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Lupus vulgaris usually begins as a collection of discrete, red-brown papules that subsequently coalesce to form an indolent, asymptomatic plaque.
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The plaque gradually reaches a size of 0.5-10 cm and develops central clearing and atrophy.
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The borders may acquire a serpiginous or verrucous quality. Hypertrophic, ulcerative and vegetative forms of lupus vulgaris may also occur.
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In Western countries, lesions often develop on the head and neck.
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In (sub)tropical areas, lesions are commonly found on the lower extremities or buttocks.
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Is it Lupus Vulgaris?
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Differential diagnosis of lupus vulgaris can be other forms of cutaneous TB, deep fungal infections, leishmaniasis, sarcoidosis.
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hypertrophic lichen planus, lichen simplex chronicus, blastomycosis.
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Lesions on the nose can mimic lepromatous leprosy, Wegener's granulomatosis and syphilis.
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Investigations done through our clinic: Abdominal ultrasound and chest x-ray normal.
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CT chest and abdomen with contrast normal. CT paranasal sinuses variable degree of pansinusitis.
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CBC normal.
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ESR 15 mm.
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LDH 204 U/L (110-295).
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ACE 99 U/L (8-52).
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Total calcium 9.5 mg/dl.
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Serum Quantiferon TB Gold negative.
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Serum galactomannan 1 (positive >=0.5) which is quite sensitive.
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Random blood sugar 78 mg/dl.
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HbA1c 5.4.
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HIV negative.
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Dermatology consultation with senior staff and revision of slide pathology.
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Rheumatology and immunology consultations.
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Eye examination and slit lamp normal.
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CT scans with contrast.
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CT paranasal sinuses.
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Chronological Lymphocytic count Follow up.
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3/2022: 1140. ESR 37, 70. LDH 944.
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7/2023: 1161. CD4 low? CD8 low?
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1/2024: 2576. ESR 66, 115.
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3/2024: 3402. ESR 15. LDH 204.
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What causes transient lymphopenia and immunodysregulation?
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Rare Case of Persistently Depressed T Lymphocyte Subsets After SARS-CoV-2 Infection.
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Male, 82-year-old. Final Diagnosis: A rare case of persistently depressed T lymphocyte subsets post COVID-19 infection.
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Symptoms: Shortness of breath. Medication: ---.
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Clinical Procedure: ---. Specialty: Immunology + Infectious Diseases.
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Objective: Unusual clinical course.
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Background: On rare occasions, viral infections are known to also depress immune cell lines, further worsening clinical outcomes.
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We describe a patient who presented 3 weeks after recovery from mild COVID-19 disease with clinical features of an atypical pneumonia.
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and was found to have a low CD4+ T-cell count.
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An 82-year-old man with a past medical history of coronary artery disease, rheumatoid arthritis, gout, hypertension, and atrial fibrillation.
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presented with a 1-week history of progressively worsening shortness of breath and cough.
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He was noted to have recovered from mild SARS-CoV-2 infection 3 weeks prior to his current presentation.
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and had been at his baseline level of health following infection.
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A T cell subset panel was obtained, which revealed an absolute CD3 count of 92.
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(reference range 840-3060), absolute CD4 count of 52 (reference range 500-1400).
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absolute CD8 count of 37 (reference range 180-1170), and a normal CD4:CD8 ratio.
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He was subsequently started on atovaquone for pneumocystis jirovecii pneumonia prophylaxis.
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Conclusion: This case highlights the need for a high index of suspicion for lymphocyte depletion in older patients with multiple comorbidities.
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who present during or after SARS-CoV-2 infection with atypical symptoms that are suggestive of immunosuppression.
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In such instances, there should be a low threshold to start prophylactic therapy for possible opportunistic infections.
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Immunological dysfunction persists for 8 months following initial mild-to-moderate SARS-CoV-2 infection.
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A proportion of patients surviving acute coronavirus disease 2019 (COVID-19) infection develop post-acute COVID syndrome (long COVID (LC)).
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lasting longer than 12 weeks. Here, we studied individuals with LC compared to age- and gender-matched recovered individuals without LC.
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unexposed donors and individuals infected with other coronaviruses.
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Patients with LC had highly activated innate immune cells, lacked naive T and B cells and showed elevated expression of type I IFN (IFN-β) and type III IFN (IFN-λ1) that remained persistently high at 8 months after infection.
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Using a log-linear classification model, we defined an optimal set of analytes that had the strongest association with LC among the 28 analytes.
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Long COVID manifests with T cell dysregulation, inflammation and an uncoordinated adaptive immune response to SARS-CoV-2.
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Long COVID (LC) occurs after at least 10% of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections.
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yet its etiology remains poorly understood. We used 'omic' assays and serology to deeply characterize the global and SARS-CoV-2-specific immunity.
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in the blood of individuals with clear LC and non-LC clinical trajectories, 8 months postinfection.
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We found that LC individuals exhibited systemic inflammation and immune dysregulation.
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This was evidenced by global differences in T cell subset distribution implying ongoing immune responses.
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as well as by sex-specific perturbations in cytolytic subsets.
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LC individuals displayed increased frequencies of CD4+ T cells poised to migrate to inflamed tissues and exhausted SARS-CoV-2-specific CD8+ T cells.
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higher levels of SARS-CoV-2 antibodies and a mis-coordination between their SARS-CoV-2-specific T and B cell responses.
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Our analysis suggested an improper crosstalk between the cellular and humoral adaptive immunity in LC, which can lead to immune dysregulation.
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inflammation and clinical symptoms associated with this debilitating condition.
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Positive history of frequent playing in farms (soil).
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Primary cutaneous Aspergillosis infection in immunocompetent host??
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Lesions include single or multiple red or violet hardened plaques, nodules, or papules at the site of skin injury.
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The lesions may be tender or symptom-free. As the lesions evolve, pus- or blood-filled blisters develop in the center.
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which eventually become necrotic blacken ulcers or scabs. Lesions most commonly appear on the limbs and head.
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and may affect a small or large area.
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Table 1 Studies on Primary Cutaneous Aspergillosis Caused by Aspergillus fumigatus, in Order of Publication and First Author.
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Mowat, 31 M/H, USA, Unknown, No, Arm, 1.2-cm hemorrhagic bulla, IV site, Amphotericin, 1 mo.
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Camus, 37 F/M, France, Farmer, No, Cheek, eyebrow, palpebra superior, erythematous nodules, Oral ITZ 400 mg/d 15 d.
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Sharma, 63 F/M, India, Farmer, No, Extremities, back, trunk, forehead, nodules plaques, Oral ITZ 200 mg/d 4 wk.
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Klieger, 24 F/M, Finland, Welder, No, Back, purpuric necrotic papules, pustules evolving into crusts, Tattoo, Oral VCZ, local TER, 4wk.
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surgical revision of necrotic tissue. Rocha, 50 F/M, India, Worker, No, Elbow, 4 x 4 cm cystic swelling, Trauma, Oral ITZ 200 mg/d 4 wk.
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Liu, 9 M/H, China, Unemployed, No, Cheek, erythematous plaque covered with flava eschar, Trauma, Oral ITZ 75 mg/d, CPX ointment.
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Rachana, 65 F/H, India, Farmer, MI, Left upper limb and trunk, swelling with pain, tightening of the skin, vesicles with watery discharge, Trauma, ITZ, 2 mo.
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Mada, 80 M/H, USA, Farmer, BCC, Right ear, erythematous swelling, Surgery, Oral VCZ 200mg/12h, 4wk, incision and drainage.
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Fan, 68 F/M, China, Unknown, Gout, HTN, Back of hand, erythematous erythema with ulceration and exudation, IV VCZ 200 mg q12h, 25 d.
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Primary Cutaneous Aspergillosis Due to Aspergillus fumigatus in an Immunocompetent Patient with Diabetes Mellitus After Tattooing: A Case Report and Review of Literature.
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A 46-year-old woman presented with erythematous papules, papulopustules, and a plaque on the right lower limb of more than two years duration without other symptoms.
