Manifestations of Infectious Diseases
Photo Essay
A Collage of Images on a Clinical Theme
Candidal Paronychia
JOE R. MONROE, PA, MPAS
Dawkins Dermatology, Oklahoma City, Oklahoma
After 6 months of suffering with an infection on her finger and several failed courses of antibiotic therapy, a 53-year-old woman sought a second opinion.
Chronic candidal paronychia was diagnosed following a culture of material from the site, which grew Candida albicans. The photograph, which contrasts the infected finger with an unaffected finger, demonstrates the typical inflammation of the periungual tissues seen in this yeast infection. The transverse ridging of the nail plate, separation of the cuticle from the nail plate, chronic edema, and slight erythema and tenderness involving the proximal paronychial tissue are characteristic of candidal paronychia.
Itraconazole, 200 mg/d for 2 weeks, followed by a topical econazole for 6 weeks resolved this infection.
Erysipelas
ROBERT P. BLEREAU, MD
Morgan City, Louisiana
Complaints of pain in an ear prompted the mother of a 4-year-old boy to seek medical consultation for her son. The external ear was red, swollen, and warm. This appearance is typical of erysipelas caused by group A ß-hemolytic streptococci.
The superficial cellulitis may appear on the face or the extensor surfaces of the legs or arms. Sites of previous lymphedema are susceptible to erysipelas.
This child was treated with penicillin, and the condition resolved rapidly.
Herpetic Whitlow
JOE R. MONROE, PA, MPAS
Dawkins Dermatology, Oklahoma City, Oklahoma
A 40-year-old dental assistant requested a prescription for antibiotics to treat the acute outbreak of painful, deep blisters that had recurred on her index finger. Prior eruptions of similar lesions had been diagnosed as staphylococcal infections and were treated with antibiotics.
A 1-cm collection of fluid-filled intradermal vesicles on a slightly erythematous area of the patient’s finger was noted. No nodes were palpable. Material from the base of a fresh vesicle was used for a Tzanck test and a tissue culture, which yielded Herpesvirus hominis, herpes simplex virus. Herpetic whitlow was diagnosed.
Prophylactic valacyclovir was prescribed for this patient. She was advised to wear latex gloves to prevent transmission of the virus.
Bullous Impetigo
ROBERT P. BLEREAU, MD
Morgan City, Louisiana
The numerous superficial, rounded, red-based ulcerations on the left buttock of a 3-year-old girl are characteristic of bullous impetigo. The varnish-like crust on the largest lesion is also typical of this skin infection.
A culture of material from one of the several vesicles containing purulent fluid grew Staphylococcus aureus, catalase-positive. S aureus is the primary pathogen in both bullous and nonbullous impetigo. The staphylococcal epidermolytic toxin causes intraepidermal cleavage below or within the stratum granulosum to produce the typical lesion. The vesicles enlarge into bullae, which rupture and may form the tinea-like scale that is seen in several lesions.
This condition usually affects exposed areas; this child’s infection may have begun with a bite or a scratch on the buttock. She was treated with oral cephalexin and topical mupirocin ointment. The bullous impetigo resolved rapidly.
Interdigital Candida
CHARLES E. CRUTCHFIELD III, MD
Eagan, Minnesota
ERIC J. LEWIS, MD
Morris, Minnesota
HUMBERTO GALLEGO, MD
La Mesa, California
A scaling, red, fissured area between digits 4 and 5 on her right hand sent a 33-year-old woman to her physician. Diagnosis of interdigital Candida was confirmed by a potassium hydroxide evaluation of material from the site.
Candidiasis of the glabrous skin has a strong predilection for the intertriginous areas of the inguinal folds, intergluteal cleft, axillae, inframammary folds,
and umbilicus. The web spaces between the third, fourth, and fifth digits of the hands also are common sites of this infection.
Treatment includes reducing exposure of the affected area to moisture and chronic maceration. A topical antifungal cream, such as ketoconazole, used with a mild hydrocortisone cream for 1 to 2 weeks, usually resolves the infection.
Herpes Zoster: Case 1
EDMOND K. H. LIU, MD,
and ALEXANDER K. C. LEUNG, MD
University of Calgary
Ten days before presenting for evaluation, a 69-year-old man began to experience neuralgic pain and noticed the eruption of painful erythematous macules and papules on the right side of his chest. Within 24 to 72 hours, vesicles and pustules arose at the site. One week after onset, several of the lesions dried and crusted.
Six months before the rash erupted, oat cell carcinoma of the middle lobe of the right lung had been diagnosed. The patient was treated with radiation therapy, and the tumor regressed.
These lesions are characteristic of herpes zoster. The patient had chickenpox as a child; reactivation of the varicella-zoster virus in the dorsal root ganglion caused the disease. The rash is usually unilateral and limited to one or two dermatomes. The thoracic region is often affected, accounting for more than half of reported cases. Herpes zoster rarely occurs below the elbows or knees.
Herpes zoster commonly afflicts immunocompromised patients like this one. The immunodeficiency may be secondary to HIV infection, malignancy, radiation therapy, or chemotherapy.
This patient was treated with intravenous acyclovir, and the lesions subsided in 14 days.
Herpes Zoster: Case 2
VIRENDRA A. PARIKH, MD
Fort Wayne, Indiana
Another manifestation of herpes zoster in an immunocompromised person appears in a 55-year-old woman. This patient was undergoing chemotherapy for metastatic breast carcinoma. Herpes zoster was heralded by itching, pain, and tenderness in the perianal region.
Groups of vesicles on an erythematous base were evident on examination. The vesicles erupted along the distribution of the nerves, causing pain.
A clinical diagnosis of herpes zoster was made, and the patient was treated successfully with topical acyclovir cream. Oral acyclovir and analgesics also can be used; rest and application of heat may be helpful. Consider systemic corticosteroids for older patients who have severe pain.
Herpes Simplex: Case 1
JOE R. MONROE, PA, MPAS
Dawkins Dermatology, Oklahoma City, Oklahoma
Multiple areas of postinflammatory hyperpigmentation over the sacral region of a 40-year-old woman had previously been incorrectly diagnosed as herpes zoster and a staphylococcal infection. A culture of material from the clustered vesicles confirmed the diagnosis of herpes simplex. The hyperpigmented lesions represent old sites of recurrent extragenital herpes simplex virus infection. With each reactivation of the latent virus, the patient experienced prodromal symptoms of burning and itching.
Valacyclovir therapy, 500 mg/d, has successfully suppressed subsequent outbreaks in this patient.
Herpes Simplex: Case 2
SCOTT J. M. LIM, DO
Lake Erie College of Osteopathic Medicine
PAUL SHIELDS, DO
Erie, Pennsylvania
A 44-year-old man experienced recurrent episodes of a burning, itchy, swollen rash on the right side of his face. He believed it to be “skin irritation from the sun.” Each episode lasted for 7 to 10 days and resolved without scarring. Lesions were always localized to the same region.
The patient was not taking any medications and denied having allergies. His physical examination was unremarkable, except for the slightly edematous, pink, crusted patch overlying the zygoma and inferior orbital ridge.
The patient recalled that the original lesion occurred soon after a rugby match 10 years earlier. His position in the game required that his head be pressed together with the heads of two other players.
No vesicles were available from which to obtain a specimen for a viral culture, but the history, recurrent nature of the lesions, association with sun exposure, and appearance supported a clinical diagnosis of herpes simplex virus infection.
The patient was treated with acyclovir without further incident. He was told that herpes is contagious and was cautioned to avoid close-contact sports while the lesion was present. The need for sun protection was emphasized, since UV light is a well-known trigger for herpes simplex outbreaks.
Herpes simplex can be transmitted by skin-to-skin contact in any sport. Herpes gladiatorum, or traumatic herpes, is seen in wrestlers who acquire the infection via body contact. Because of the potential for ocular involvement, reinforce the need to avoid close contact until the crusted lesions have disappeared.