Red, necrotic papule and lymphadenopathy in an immunocompromised patient: Case report

Emily L Clarke; Tyler J Willenbrink; Brett Keeling

doi:10.4103/jdds.jdds_66_20

CASE REPORT

Year : 2021 | Volume : 25 | Issue : 2 | Page : 131-133

Red, necrotic papule and lymphadenopathy in an immunocompromised patient: Case report

Emily L Clarke¹, Tyler J Willenbrink², Brett Keeling³
¹ Dell Medical School, University of Texas, Austin, Texas, USA
² Department of Medicine, Division of Dermatology, Dell Medical School, University of Texas, Austin, Texas, USA
³ Department of Medicine, Division of Dermatology, Dell Medical School, University of Texas; Division of Dermatopathology, Clinical Pathology Associates, Austin, Texas, USA

Date of Submission	12-Jun-2020
Date of Acceptance	07-Feb-2021
Date of Web Publication	29-Mar-2022

Correspondence Address:
Dr. Tyler J Willenbrink
Division of Dermatology, 1701 Trinity St., Ste 7.802. Austin, Texas 78712
USA

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdds.jdds_66_20

Abstract

Immunocompromised patients, including those with acquired immunodeficiency syndrome (AIDS), are susceptible to a variety of opportunistic infections, cutaneous malignancies, and other skin lesions, which can present with nonspecific cutaneous findings. Herein, we present the case of a 28-year-old male with AIDS who presented with fatigue, left axillary lymphadenopathy, and a necrotic, red papule on the left upper arm. This case reviews the differential diagnosis of this presentation in an immunosuppressed patient including the key pathological findings.

Keywords: Bacillary angiomatosis, Bartonella henselae, cat-scratch disease, dermatopathology, immunocompromised, infectious disease

How to cite this article:
Clarke EL, Willenbrink TJ, Keeling B. Red, necrotic papule and lymphadenopathy in an immunocompromised patient: Case report. J Dermatol Dermatol Surg 2021;25:131-3

How to cite this URL:
Clarke EL, Willenbrink TJ, Keeling B. Red, necrotic papule and lymphadenopathy in an immunocompromised patient: Case report. J Dermatol Dermatol Surg [serial online] 2021 [cited 2022 Jul 2];25:131-3. Available from: https://www.jddsjournal.org/text.asp?2021/25/2/131/341211

Introduction

Immunocompromised patients, including those with acquired immunodeficiency syndrome (AIDS), are susceptible to a variety of opportunistic infections, including uncommon disseminated infections such as bacillary angiomatosis (BA). BA is known to mimic other skin lesions such as pyogenic granulomas and Kaposi's sarcoma due to its nonspecific cutaneous findings. The presentation of a friable, red papule in an immunocompromised patient can, therefore, elicit a broad differential diagnosis, relying on histopathology for a final diagnosis. Herein, we present a case of BA in an AIDS patient and discuss the pathological findings that distinguish BA from other clinical imitators.

Case Report

A 28-year-old male with AIDS on antiretroviral therapy presented with 2 weeks of nausea, fevers, and malaise in conjunction with a growth on the left upper arm. The patient stated that the lesion began as a small, red bump that frequently bled. He denied other skin or mucosal findings, but did report night sweats, dysphagia, and diarrhea over the preceding week. On examination, the patient was febrile to 102.4° and tachycardic. He was cachectic with tender left axillary lymphadenopathy and a 5-mm necrotic papule with an erythematous border present on the left upper, lateral arm [Figure 1]. There were numerous excoriations and hypopigmented, depressed scars on his extremities which were secondary to cat scratches.

Figure 1: Necrotic papule with an erythematous border present on the patient's left upper arm

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Laboratory evaluation was notable for a white blood cell count of 3100/mm³, lactate dehydrogenase of 795 U/L, and CD4 count of 58/μL. Computed tomography scan of the chest and abdomen showed left axillary and mild subcarinal lymphadenopathy with splenomegaly, splenic hypodensities, and heterogeneity of the pancreatic head and neck. The patient underwent a punch biopsy of the solitary skin lesion on the left lateral, upper arm.

The punch biopsy demonstrated an infiltrative, nodular proliferation of irregularly shaped vascular channels in the dermis stuffed with red blood cells. The endothelial cells contained enlarged, vesicular nuclei with prominent nucleoli and occasional mitoses, which stained positive for CD31 and factor VIII but negative for human herpesvirus-8 [Figure 2]. There were also amorphous bacillary-like structures identified within the dermis with Grocott's methenamine silver stain [Figure 3].

Figure 2: Biopsy revealed irregularly shaped vascular channels and endothelial cells with enlarged, vesicular nuclei with prominent nucleoli and occasional mitoses (H and E, ×400)

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Figure 3: Amorphous bacillary-like structures present in the dermis (Grocott's methenamine silver stain, ×400)

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These findings, in conjunction with the patient's history and physical exam, rendered a diagnosis of BA. The diagnosis of disseminated BA was confirmed by polymerase chain reaction (PCR)-positive nodal tissue for Bartonella henselae. The patient underwent 2 weeks of intravenous gentamicin along with 4 weeks of doxycycline, which led to resolution of his symptoms.

Discussion

Necrotic, red papules in an immunocompromised host elicit a wide differential including Kaposi's sarcoma, angiosarcoma, pyogenic granuloma, and various infectious agents (Bartonella, Rickettsia, Francisella, Mycobacterium tuberculosis, and other opportunistic organisms). While pathology can often guide diagnosis, it can be challenging to distinguish BA from other causes microscopically.

Inflammatory debris and neutrophilic infiltrate are suggestive of a bacterial infection, including BA, and can be useful in differentiating this disease from Kaposi's sarcoma. The basophilic bacillary organisms responsible for the infection are often seen on skin pathology.^[1] Special stains, such as the Warthin–Starry stain, are also helpful in diagnosing BA, and PCR can often serve to confirm the diagnosis. Angio-proliferative tumors such as Kaposi's sarcoma are notable for enlarged vascular channels filled with red blood cells and usually stain positive for human herpesvirus-8. Compared to pyogenic granulomas, cell morphology in BA is notable for larger and more atypical cells.^[1]

In the immunocompetent host, Bartonella infections, also called cat-scratch disease, usually manifest as self-limited, tender lymphadenopathy. However, immunocompromised hosts can develop a disseminated vasculo-proliferative form known as BA. This infection is often invasive with the potential to spread to other sites including the brain, eyes, heart, lymph nodes, and gastrointestinal organs.^[2] BA typically presents with fever and lymphadenopathy within a week of inoculation followed by enlarging red-purple vesicles or papules, often with episodes of bleeding reminiscent of pyogenic granulomas.^[2],[3] Other cutaneous presentations include friable, exophytic nodules and subcutaneous masses associated with cellulitis-like skin changes often overlying interosseous lesions.^[4]

There are several species of Bartonella, but only a few are known to infect humans, most commonly B. henselae and Bartonella quintana.^[3] B. henselae is transmitted to humans by the domestic cat, which is the natural host for the organism. The bacterium is transmitted either directly through a scratch or bite or indirectly through the cat flea or tick.^[2],[3] Unlike B. henselae, B. quintana's natural host is believed to be humans. This species is transmitted by the human body louse and is common in impoverished and indigent populations.^[3]

B. henselae infection in the immunocompetent host is self-resolving and does not require treatment. However, there are significant risks of untreated infection for immunocompromised patients, given the risk of dissemination to multiple organ systems including the nervous and cardiovascular systems.^[2] Treatment of BA requires a combination of gentamicin and doxycycline to increase the speed of illness resolution in chronic bacteremia or disseminated disease.^[5]

The differential diagnosis for red, necrotic papules in immunocompromised patients is extensive. This case highlights the importance of histopathology in diagnosing opportunistic infections with nonspecific cutaneous symptoms in immunocompromised patients. Despite the patient's limited cutaneous findings, skin biopsy of the lesion on his arm was instrumental in confirming the diagnosis and guiding the appropriate treatment for his disseminated infection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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