UPMC Dermatopathology "Case of the Month" Presentations
UPP - Department of Dermatology, Dermatopathology Unit
Holly R. Mason, MD, PhD, Douglas W. Kress, MD, Jonhan Ho, MD
NOVEMBER 2007 CASE OF THE MONTH
CLINICAL FINDINGS
3 year old white male was seen at Children’s Hospital of Pittsburgh while an inpatient for dehydration. He had a history of a liver and small bowel transplant 5 months earlier for gastroschisis and TPN cholestasis which was complicated by Mycobacterium abscessus peritonitis and treated with amikacin, clarithromycin, imipenem, and linezolid. He was only on clarithromycin at the time of our initial meeting. Per his mother’s history, he developed erythematous, crusted lesions over his abdominal incisions for 6 weeks, and we were consulted for further evaluation. These lesions were painful and draining serosanguinous fluid. His mother denied history of fever but noted that she was able to see the sutures at his flanks before this reaction began. Of note, polydioxanone (PDS) sutures were used to close the fascia in his transplant operation and staples were used to close the skin. He had no other operations since the transplant.
His past medical history also included short gut syndrome and line infections. His medications included clarithromycin, Prograf, cyproheptadine, Neupogen, Prevacid, Reglan, nystatin, MVI, prednisone, and Actigall.
Physical Exam
Erythematous, crusted plaques overlying extensive abdominal incisions (Figure 1).
Differential Diagnosis
Infection (bacterial, fungal, atypical mycobacterial), suture reaction
Histopathology
Histopathological examination of a biopsy from the abdominal wound revealed pseudoepitheliomatous hyperplasia with a diffuse dermal infiltrate composed of granulation tissue and numerous macrophages and foci of caseating necrosis (Figure 2). Fite and AFB special stains were positive for numerous filamentous organisms (Figure 3).
Figures & Images
Figure 1. Erythematous, crusted plaques overlying extensive abdominal incisions.
Figure 2. (H+E) Granulation tissue with numerous macrophages and caseating necrosis
Figure 3. Acid-fast stain revealing presence of mycobacteria
.
GO TO FIGURE AND IMAGE REVIEW PAGE