Rare Infections

Ron Rapini MD, Chernosky Chair, Dept Dermatology, Professor of Pathology

Univ Texas Medical School at Houston &

MD Anderson Cancer Center

No conflicts of

interest – No stock in

stores that sell rapini

Format – presentation of 12 unusual

cases

Well, we won’t get through them all

Case 1. Forearm plaque, 40-year-old woman

Sent biopsy to me for dermpath

second opinion

• Dermatologist: “Probable

keratoacanthoma”

• Dermatopathologist: Yes,

“C/W keratoacanthoma,

transected at base”

“garbage in, garbage out

phenomenon”

“Has patient traveled

anywhere?”

•Answer: Costa Rica

and Missouri

Leishmania – call CDC for N,N,N

media (Nicolle-Novy-MacNeal)

• Ship to you free of charge

• Speciation done by CDC in Atlanta,

Georgia, USA

• Speciation important for prognosis

determination

Two weeks post-excision: very happy (like most of my patients)

Rx recommended by

CDC• Ketoconazole 200 mg t.i.d for one

month

(many other anecdotal treatments

have been used: itraconazole,

allopurinol, topical antimony,

cryotherapy, etc)

After one month ketoconazole

Sporotrichoid – “SLANT”

• S = Sporotrichosis

• L = Leishmaniasis

• A = Atypical mycobacteria

• N = Nocardiosis

• T = Tularemia

Time to refer to infectious disease

service for IV Pentostam (antimony)

– CDC ships free of charge

• Antimony causes EKG abnormalities – patient found to have cardiomyopathy

• So… was treated with good result with IV pentamidine

Leishmaniasis sp.• L. tropica = oriental sore, Middle East, self-

healing

• L. mexicana = Central and South America,

self-healing

• L. braziliensis = Central and South America,

aggressive course with risk mucocutaneous

spread

This patient grew L. panamensis, related to

braziliensis

L.guyanensis -

Equador

L.guyanensis -

Equador

L.guyanensis - Equador

L.guyanensis -

Equador

L.guyanensis –

Equador –

sporotrichoid!

Case 2:

Photo by KhanhNguyen MD

Case 2

• Lived in a refugee camp for 10 years

• Admitted to hospital 3 days after arrival

in the US

• No HIV meds, CD4 = 8

• Fever, sepsis, malaise, weight loss

• Cachectic, hypotensive,

lymphadenopathy, rales,

hepatosplenomegaly

Talaromyces (formerly Penicillium) marneffei

Talaromyces (Penicillium) marneffei - GMS

Nguyen K, Taylor S, Wanger A, Ali A, Rapini RP: A

case of Penicillium marneffei in a US hospital. J Am

Acad Dermatol 54:730-732, 2006

Histoplasma

Leishmania

Cryptococcus

Penicilliosis• Endemic in Southeast Asia

• Mainly in the immunosuppressed

• AIDS-defining disorder

• Reservoir uncertain – bamboo rat?

• Probably acquired by inhalation

• Average CD4 count is 64 cells/mL

Penicilliosis findings

• Papules resemble molluscum, acne

• Face (forehead) more than arms, trunk,

sometimes mouth

• Infection can be localized or disseminated

• Bone marrow 54%

• Blood 15% (intracellular or extracellular)

• Liver, spleen, lung

• ELISA, PCR has been used to identify

Penicillium marneffei• The only dimorphic Penicillium

species (but now is Talaromyces)

• Mold at 25 degrees, yeast at 37

• Organism at high power divides by

fission, not by budding

• Some cells elongated like sausages,

some with crosswalls

Penicilliosis treatment• High mortality without treatment

• Responds in 7 days with treatment, but long term treatment needed, often recurs

• Liposomal amphotericin B (Ambisone), itraconazole, ketoconazole, voraconazole

• Our patient did well on Ambisone and itraconazole

Case 3

• “Doc, I think I’ve got worms in

my head so I shaved my head

so you can see them”

“I just got back from Belize, in

Central America, where I was

looking for reptiles for the

Houston zoo.”

Anus

Dermatobia hominis

As in most of my patients,

the treatment was curative,

and he never came back

Several months later…

• Another patient, also having returned from Belize, working in oil exploration, complained: “I think I have some kind of worm in my leg, because I can see him moving in this hole.”

(case 4)

Human bot fly,

Dermatobia hominis

Furuncles with “breathing holes”

Travel to Central or South

America

Surgery not needed – use pork

fat, beef, petrolatum, gum, etc!

Specific myiasis – a particular

maggot prefers a specific host

Nonspecific myiasis – flies lay

eggs on any old rotting flesh

(such as old leg ulcer)

“Specific” myiasis• Cordylobia

(tumbu fly)

• Dermatobia (human botfly)

• Callitroga (screw worm)

• Chrysomya (Old World screw worm)

• Africa

• Central and S.

America

• Warm western

hemisphere

• Ethiopia

Specific myiasis (worldwide)

• Hypoderma

• Oestrus

• Gasterophilus

• Cuterebra

• Wohlfahrtia

• Cattle botfly

• Sheep botfly

• Horse botfly

• Rodent botfly

• Flesh fly

Courtesy Phil Cohen MD

Case 5: “Something is

biting me”

4-5 mm when unfed!

Bedbugs

• Everyone knows about

them, but few patients and

dermatologists have seen

them

• Three species: Cimex

lectularius is most common

Bedbugs

• Hide in bedclothes, mattresses, bed

frame, cracks in building, under

wallpaper

• Often congregate; if many, there

can be a sweet odor

• Feed only 5 minutes at night

• Painless bite, but saliva causes

urticaria, rarely bullae

Bedbugs

• Also bite chickens, bats, some

domestic animals

• Urticarial reaction to saliva

injected through sucking tube

mouthpart

• Hepatitis B DNA found in

bedbugs; unproven to spread this

and other infectious agents

Bedbugs Rx

• Heat: 120 degrees F to kill them

• Or freeze them several days

• Insecticides are not highly

effective. Pyrethroids will kill

them but not prevent egg laying

and will not repel them

Bedbugs Rx

• Bedbug sniffing dog

• Nightwatch trap: kairomones and

carbon dioxide attractant

• Hotels want to sue

bedbugregistry.com

Bedbugs PREVENTION

• Keep suitcase far from bed and

keep it zipped up

• Put suitcase on the stand with the

metal legs

Case 6 Forearm ulcer after local trauma in

Mexico

DP-88-4892

DP-88-4892

DP-88-4892

Gram stain

DP-88-4892 GMS

Nocardia asteroides

Nocardia braziliensis• Pulmonary, CNS, Skin

• Gram+, GMS+, AFB+

• Sulfur granules sometimes

• Grows is 2-5 days in blood agar or routine culture,

but lab has to hold it longer

• Aerobic, unlike Actinomyces

Case 6 Nocardiosis

• Primary inoculation non-systemic form often resolves spontaneously

• Trimethoprim-sulfamethoxazole DS bid for 2 to 4 weeks

• F/U on this case – healed readily with above Rx

7. Brown macule, palm

7. Tinea nigra• Brown patch may resemble lentigo,

macular SK, pigmented Bowen’s

• Surgery sometimes done when mistaken for melanocytic neoplasm

• Culture or KOH prep positive

Formerly Cladosporium, Exophiala, then Phaeoannellomyces

Now Hortaea werneckii

Times are a changin’ – constant renaming

• Penicillium marneffei, now Talaromyces

• Cladosporium, Exophiala,

Phaeoannellomyces, now Hortaea

werneckii

• Pityrosporum orbiculare or ovale, now

Malassezia furfur

• Paracoccidiodes loboi, Lobo loboi, now

Lacazia

Times are a changin’ – nonfungi too

• Chancroid’s Calymmatobacterium,

Donovania, now Klebsiella granulomatis

• Cat scatch’s Rochalimaea, now Bartonella

henselae

Me too’s – additional agents

• Leprosy’s Mycobacterium leprae, also M.

lepromatosis

• Coccidioidomycosis’ Coccidioides

immitis, also C. posadasii

• S. Amer Blasto’s Paracoccidioides

braziliensis, also P. lutzii

Tinea nigra

prep from culture, tinea nigra

Another one,

case 7b

This time, tinea nigra proven from KOH prep

without biopsy

8. Rare annular form of chromomycosis

VA 82-1225

VA 82-1225

VA 82-1225

8. Chromomycosis

• Usually adult males, esp farmers

• Black dots may be seen

• KOH may be positive

• Culture for speciation

• Excision may be curative as

opposed to antifungal Rx

Chromomycosis SMA 1986 #17

Chromomycosis SMA 1988 #23

8. Chromomycosis• Pseudocarcinomatous hyperplasia

• Intraepithelial microabscesses

• Granulomatous inflammation

• Copper pennies = Medlar bodies =

sclerotic bodies, 6-12 microns,

planate-dividing (cissiparity)

• Phaeohyphomycosis is different

(brown hyphae instead of spores)

Chromomycosis

Dematiaceous (brown) fungi

• Phialophora verrucosa

• Fonsecaea pedrosoi

• Fonsecaea compacta

• (Hormodendrum)

• Exophiala sp

• Cladosporium carrionii

Dematiaceous fungi

• The brown pigment is indeed melanin – can

do Fontana melanin stain (not needed)

Case 9

Phaeohyphomycosis

• Painful nodule on knee x 1 year:

“KA vs prurigo”

Phaeohyphomycosis – hyphae

Sulfur

granule

from

draining

sinus tract

of

Mycetoma

10. Sporotrichosis: DP03-3123

Sporotrichosis: Asteroid bodies

Sporotrichosis: yeast and cigar bodies

Sporotrichosis histology

• Often see NO organisms, deeper

levels help

• Most commonly just see budding

yeast averaging 3-8 microns

• Sometimes cigar bodies

• Sometimes asteroid bodies

Sporotrichosis –

often Sporotrichoid

spread

Case 11 complaint of worms/fibers –jungle of Peru

I gave a talk at AAD in 2007 on

Morgellons disease when it was

“new” – one of the biggest

mistakes of my life

Now the dermatologists in Houston send

them all to me, or eventually the

patients find me, as they go from doc

to doc, and I average one of these per

week

History of Morgellons disease

• pronounced mor-GELL-uns

• Named in 2002 by Mary Leitao.

• Woman with B.S. in Biology who says her

son suffers from the condition, founded the

Morgellon’s Research Foundation

History of Morgellons disease

• Sir Thomas Browne in 1674: “children of

Languedock, called the Morgellons,” wherein

they break out with “harsh Hairs on their

Backs”

• Described in 1544 by Faventinus as an

intercutaneous worm of children that

“protrude their little heads”

Morgellons Research Foundation

http://www.morgellons.org/

• 9045 registered households in Feb 2007

• #1 California, #2 Texas

• #1 Nurses, #2 Teachers

2012: The Morgellons Research

Foundation (MRF) is no longer

an active organization and is not

accepting registrations or

donations.

The MRF donated remaining

funds to the Oklahoma State

University Foundation to support

their Morgellons disease

research.

Charles Holman Morgellons

Disease Foundation

Named for husband of

affected patient (an RN)

10th Annual Conference on

Morgellon’s Disease (and rally)

April 29, 2017 – May 1, 2017

Austin, Texas

Morgellons disease: a chemical and light

microscopy study

Middelveen MJ, Rasmussen EH, Kahn DG,

Stricker RB. J Clin Exp Dermatol Res. 2012

“This study puts the final nail in the coffin of

delusional disease that these patients have been labeled

with,” stated Dr. Stricker . “It proves that Morgellons

disease is a physiologic illness.”

Telling The Truth You Were

Never Supposed To Know

http://www.morgellonsexposed.com/

“People who suffer from Morgellons

disease are NOT delusional no matter

what the CDC or the mainstream press

would have you believe.”

Morgellons Research Foundation

Case Definition (CDC also investigated)

1. Skin lesions

2. Crawling sensations

3. Fatigue

4. Cognitive difficulties (“brain fog”)

5. Behavioral effects (“labeled as delusional parasitosis”)

6. Fibers (usually white, also blue, green, red, black, fluoresce with Wood’s lamp)

Morgellon’s disease online

• Google search:

15,400 hits as of 2007

1,270,000 results in Aug 2012

191,000 results Mar 2017

• A “disease caused by the internet?” or

“mass hysteria” vs a bonafide unidentified

fiber or organism

“Morgellon’s is biowarfare”

• www.rense.com

• “…may be a logical reason for our

advanced high-tech medical system to

drag its feet”

http://rense.com/Datapages/morgdat1.htm

CDC creeps formally call Morgellon

an hallucination

The CDC and NIH knew and know

http://www.cdc.gov/unexplaineddermopathy/

Clinical, Epidemiologic, Histopathologic and Molecular

Features of an Unexplained Dermopathy

Michele L. Pearson1, Joseph V. Selby2, Kenneth A. Katz3,

Virginia Cantrell2, Christopher R. Braden4,

Monica E. Parise5, Christopher D. Paddock6, Michael R.

Lewin-Smith7, Victor F. Kalasinsky8, Felicia C.

Goldstein9, Allen W. Hightower5, Arthur Papier10,

January 2012 | Volume 7 | Issue 1 | e29908

www.plosone.org

Usefulness of term Morgellon’s

• “A rapport-enhancing term” but “should

not validate a condition” and doc should

clarify “not infectious agent” per Drs

Murase, Wu, Koo. JAAD 2006

• Better than putting “Delusions of

parasitosis” on path requisition: patients

often ask for copy of path report

• Use term R/O “acariasis” instead

Morgellon’s disease treatment –

my non-expert approach (don’t

want to be labeled as an expert)

My approach: Serious look for bugs by

scraping or biopsy, give antiparasite

treatment along with SSRI or other psych

drug for the “stress” – be gentle and

empathetic - they won’t go to psych and

many get angry

A thrip (Thysanoptera): sucks plant juices:

(sometimes they bring in real, but

irrelevant bugs)

Morgellon’s disease treatment –

off-label drugs to gain rapport

(to add to “stress treatment”)

• Topical permethrin, lindane

• Topical crotamiton is also antipruritic

• Topical sulfur products (rosacea products)

• Oral ivermectin

Morgellon’s disease off-label treatment –

treat the stress AND the ?parasites

• pimozide: no prolonged Q-T problems or tardive

dyskinesia if less than 10 mg/day – may not need

EKG. Start 1 mg/day, increase by 1 mg/day every 4

– 7 days. Most patients effective at 4 – 6 mg/day.

Claimed to be antipruritic. Treat extrapyramidal

effects with benztropine myselate 1 – 4 mg IM or

diphenhydramine 25 mg q.i.d

Morgellon’s disease off-label treatment –

treat the stress AND the ?parasites

• olanzapine: start 5 – 10 mg/day, effective dose

10 – 15 mg/day: weight gain, hyperlipidemia,

diabetes, less extrapyramidal

• risperidone: for bipolar or schizophrenic

disorders

• quetiapine: for psychosis

Other drugs off label (I am not expert – better to use

with psychiatrist if you can get patient to agree to it)

• SSRI: citalopram

• SSRI: escitalopram

• SSRI: paroxetine

• SSRI: sertraline

• SSRI: fluvoxamine

• Antidepressant: duloxetine

Alternative approach (not favored by me)

• Confront these patients and tell them

you think they are delusional and that

they need psych drugs

• Tell them they can continue to be

frustrated and go from derm to derm

until they finally have the insight to take

the psych drugs

“Morgellon’s”

I think that these patients at least

need to be taken seriously and a

sincere look for parasites ought to

be undertaken on the first visit

Case 12. Poor old woman, saw multiple docs, labeled

as crazy Morgellon’s disease patient – brought in

the usual “bug” samples to examine

She had had exterminators come

to her house on at least three

occasions

This thing fell from her coat

onto the floor as she was

leaving the exam room!