Generalized perforating granuloma annulare (GPGA) is a very rare form of granuloma annulare, with only 31 reported cases to the best of our knowledge. Furthermore, GPGA is a chronic disease that mimics many diseases, with no known exact etiology, resulting in a lack of specific clinical criteria leading to a lack of guidelines for diagnosis and therapy. In GPGA, papules are the predominant lesions followed by central crusting/scaling or umbilication; pustules, plaques, annular lesions or nodules are less frequent. We report a 66-year-old woman who presented with a 7-month history of mostly asymptomatic generalized infiltrated, flesh-colored to red-brown umbilicated or crusted papules. Histopathological findings were compatible with perforating granuloma annulare. Diagnostic workup revealed latent tuberculosis. To the best of our knowledge, this is the second published case of GPGA associated with latent tuberculosis and the first one that was successfully treated by isoniazid monotherapy. From our case we can speculate and support the theory that GPGA is a phenotypic granulomatous response to multiple etiologies and/or antigenic stimulation and that testing for tuberculosis should be seriously considered in the evaluation of patients with GPGA.

[West J Emerg Med 2013;14(2):163.]

We present the case of a 72-year-old man with a one-week history of a red rash on the palms of both hands. A 4mm punch biopsy revealed interstitial granulomatous inflammation within the dermis and a colloidal iron stain showed increased dermal acid mucin. Immunohistochemical staining for CD68 confirmed the presence of abundant histiocytes within the dermis. The clinical and pathological correlation was consistent with the diagnosis of interstitial granuloma annulare. Exclusive involvement of the palms is a rare presentation and serves as a reminder for practitioners to keep granuloma annulare in their differential diagnosis when observing palmar plaques.

Omphaloliths are uncommon benign umbilical lesions caused by the accumulation of sebum and keratin into a stone-like concretion. Recognition of this entity can prevent unnecessary procedures and imaging studies for uncomplicated cases. We present three cases of omphaloliths from our department and review all 26 cases previously reported in the English literature with regard to modes of presentation, potential risk factors, complications, and treatment options to guide clinicians. The mean age at presentation was 48 years. Of the 29 cases, 17 (59%) were asymptomatic. Male patients presented at a younger age and were more likely to present with complications compared to females who presented at an older age with asymptomatic lesions (P=0.006). Features of patients described included dementia, hirsutism, a deep or narrow umbilicus, multiple nevi, obesity, and poor hygiene. Two patients developed overlying pyogenic granulomas. Removal of asymptomatic lesions was uncomplicated and done using forceps or following irrigation, with no recurrence. Complications, including localized abscesses and peritonitis, were associated in 41% of patients who were treated surgically; recurrence was noted in one patient. Removal of omphaloliths is recommended, once identified, to reduce risks of complications and patients should be encouraged to improve their personal hygiene.

Granuloma annulare (GA) is a benign, granulomatous disease with several clinical manifestations, which include localized, generalized, perforating, subcutaneous, patch, papular, and linear forms.  We report a case of papular GA of the dorsal aspects of the hands that arose after repeated, direct trauma to the site of subsequent involvement.  Although multiple etiologies for GA have been proposed, which include ultraviolet light, arthropod bites, trauma, tuberculin skin tests, viral infections, and PUVA photochemotherapy, the underlying pathogenesis of the disorder remains unclear.  However, owing to the key histopathologic findings of focal collagen and elastic fiber degeneration and mucin deosition in GA, it is not surprising that cutaneous trauma may have played a role in connective tissue injury, subsequent degeneration, and the production of a granulomatous response with increased mucin deposition.

Cryptococcosis is a rare opportunistic infection with morphologically diverse cutaneous presentations. Primary infection typically occurs in the lungs with subsequent hematogenous dissemination to other organ systems, especially in immunocompromised patients. Herein, we report a woman in her 70's who presented with pruritic, umbilicated papulonodules of the bilateral upper and lower extremities present for many weeks. She was diagnosed with disseminated Cryptococcus and subsequently evaluated for potential pulmonary and meningeal disease involvement. She died as a result of multiple medical comorbidities.

Purpose

Nitazoxanide was recently reported as having in vitro effectiveness against the rubella virus. Immunodeficiency-related vaccine-derived rubella occurs in some patients who have an inherited immunodeficiency and who received the MMR vaccine. This study investigated the in vivo effectiveness of nitazoxanide therapy.

Methods

This is a retrospective analysis of seven patients treated with nitazoxanide as salvage therapy for immunodeficiency-related vaccine-derived rubella infection. The patients were recruited from an ongoing rubella detection surveillance project.

Results

Seven patients with persistent rubella were treated with nitazoxanide and one demonstrated significant clinical improvement. Two additional patients exhibited diminished viral capsid production with one patient having transient slowing of progression. The cohort overall generally had low T cell counts and had a high burden of comorbidities. There were three deaths. Two deaths were from PML and one was related to hematopoietic stem cell transplantation.

Conclusions

Nitazoxanide has limited in vivo anti-viral effects for immunodeficiency-related vaccine-derived rubella. Most patients did not exhibit clinical improvement.

La endometriosis umbilical primaria se caracteriza por la aparición de lesiones nodulares a nivel umbilical sin la presencia de intervenciones quirúrgicas abdominales previas ni presencia de endometriosis conocida en otras localizaciones. Presentamos el caso de una mujer de 43 años que presenta dicha entidad. Con este caso queremos destacar la importancia del diagnóstico diferencial de las lesiones nodulares a nivel umbilical sobre todo en mujeres en edad fértil.The onset of umbilical nodules with no previous abdominal surgeries or known endometriosis in other locations characterizes primary umbilical endometriosis. We present a 43-year-old woman with a painful umbilical nodule for several months. We report this case to emphasize the importance of the differential diagnosis of umbilical nodules, especially in women during the reproductive period.