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Posttransplant lymphoproliferative disorders are lymphoid proliferations or lymphomas, usually associated with Epstein-Barr virus infection, that develop as the consequence of immunodepression. These disorders usually affect patients receiving high doses of cyclosporine in the context of bone marrow or organ transplantations. Posttransplant lymphoproliferative disorders can regress when cyclosporine is discontinued. Such lymphoproliferations rarely occur for patients receiving low-dose cyclosporine treatments for autoimmune disorders. In the following report, we describe a patient with psoriasis vulgaris treated with long-term low-dose cyclosporine who developed an acute Epstein-Barr virus-associated clonal lymphoproliferative disorder associated with hemophagocytic syndrome. This lymphoproliferative disorder resembling classic posttransplant lymphoproliferative disorder regressed when cyclosporine was discontinued.

Background Renal transplant recipients are predisposed to superficial fungal infections caused by graft-preserving immunosuppressive therapy. Reports have documented a wide range of prevalence rates for superficial fungal infections in this patient group. Objective The aim of this study was to determine the prevalence and clinical and mycological features of superficial fungal infections in renal transplant recipients at our center. Methods One hundred two consecutively registered renal transplant recipients (34 women, 68 men) and 88 healthy age- and sex-matched persons acting as controls (30 women, 58 men) underwent screening for the presence of superficial fungal infection. Skin scrapings and swabs were obtained from the dorsum of the tongue, upper part of the back, toe webs, and any suspicious lesions. Nail clippings were also collected. All samples were examined by direct microscopy and were stained with calcofluor white. The samples were cultured in Sabouraud dextrose agar, mycobiotic agar, and dermatophyte test medium. Candida species were identified on the basis of germ-tube production, spore formation in cornmeal agar, and results of biochemical testing. Dermatophytes were identified on the basis of colonial and microscopic morphologic features in conjunction with results of physiologic evaluation (in vitro hair perforation test, urease activity, temperature tolerance test, and nutritional test). Results Sixty-five (63.7%) of the 102 renal transplant recipients had cutaneous-oral candidiasis, dermatophytosis, or pityriasis versicolor, whereas only 27 (30.7%) of controls had fungal infection. Pityriasis versicolor was the most common fungal infection in the patient group (36.3%), followed by cutaneous-oral candidiasis (25.5%), onychomycosis (12.7%), and fungal toe-web infection (11.8%). Pityriasis versicolor and oral candidiasis were significantly more common among the renal transplant recipients, whereas the frequency of dermatophytosis in patients and controls was similar. Candida albicans was the main agent responsible for oral candidiasis, and Trichophyton rubrum was the most common dermatophyte isolated. Analysis showed that age, sex, and duration of immunosuppression did not significantly affect the prevalence of superficial fungal infection. Cyclosporine treatment and azathioprine therapy were identified as independent risk factors for superficial fungal disease. Conclusions The prevalence of opportunistic infections with Pityrosporum ovale and C albicans is increased among renal transplant recipients, probably owing to the immunosuppressed state of this patient population. However, renal transplant recipients are not at increased risk of dermatophytosis.

Relapsing varicella may occur in children with HIV infection and more rarely in younger adults. Our aim was to report unusual clinical, histologic, and virologic aspects of 4 elderly patients with malignant hemopathies who had an unusual form of recurrent varicella develop. Conventional microscopy, immunohistochemistry, and in situ hybridization were applied to smears and skin biopsy specimens. The patients presented a few dozen, scattered, large, papulovesicular lesions with central crusting. No zoster-associated pain or dermatomal distribution of the lesions was noted. Conventional microscopy revealed vascular changes and epidermal alterations typical for α-herpes virus infection. The varicella zoster virus major viral envelope glycoproteins gE and gB, and the immediate-early varicella zoster virus IE63 protein and the corresponding genome sequence for gE were detected on Tzanck smears; they were localized in endothelial cells and keratinocytes on skin biopsy specimens. The varicella zoster virus infection in endothelial cells, the vascular involvement, and the widespread distribution of the lesions suggest that the reported eruptions are vascular rather than neural in origin. These findings invalidate the diagnosis of herpes zoster but strongly support the diagnosis of recurrent varicella in an indolent and yet unreported presentation. Furthermore, these eruptions differ from relapsing varicella in children and young adults by the age of the patients, the paucity of clinical lesions, the larger diameter of the lesions and their peculiar clinical aspect, the significantly longer time interval between primary varicella and the recurrence, the prolonged healing time of the lesions, their mild disease course, and the fact that all the lesions are in the same stage of development. (J Am Acad Dermatol 2003;48:442-7.)

Background Opportunistic infections (OIs) can be defined as infections in immunosuppressed patients that are more frequent or severe because of immunosuppression. The literature on OIs in pemphigus is sparse. Objective We assessed the incidence, risk factors, and characteristics of OIs in patients with pemphigus. Methods This was a historical prospective study following a cohort of 172 patients with newly diagnosed pemphigus for the development of OIs. Results Fourteen patients developed OIs at a mean of 4 months from the time of diagnosis while taking a mean dose of 0.8 mg/kg/day of prednisone, 5 in conjunction with azathioprine. The risk of developing an OI in the first year after the diagnosis of pemphigus was 9.3%, subsequently dropping to 0. Advanced age and possibly diabetes were found to be risk factors for OI development. Infectious agents included Nocardia, cytomegalovirus, Legionella, and Listeria. Two patients died within 2 months of OI diagnosis, and 2 more had neurologic impairment. Limitations Limitations include the extraction of historical data and the cohort originating from a single geographic region. Conclusion OIs present in a significant number of patients with pemphigus during the first year after the diagnosis of pemphigus, with potential deleterious effects. Older and possibly diabetic patients are at increased risk. Physician vigilance and patient education on limiting pathogen exposure is recommended.

Two HIV infected patients with visceral leishmaniasis and unusual cutaneous lesions are described. The first patient developed linear brown macules containing Leishmania parasites on the fingers and palms of the hands. This patient never received highly active antiretroviral treatment and the visceral leishmaniasis could not be cured even with liposomal amphotericin. In the second patient, Leishmania parasites were present in a skin biopsy of a fibrous histiocytoma. After completing visceral leishmaniasis treatment, a discrete elevation of one of his tattoos was seen. A biopsy specimen of this tattoo revealed Leishmania amastigotes. In this patient the visceral leishmaniasis was finally cured with meglumine antimoniate, followed by pentacarinat isothianate as maintenance therapy in conjunction with highly active antiretroviral treatment.

Human papilloma virus (HPV)-related cutaneous manifestations occur with increased frequency and severity among HIV-infected persons. In this report, we describe an HIV-infected man with persistent, severe cutaneous hand warts that did not respond to multiple therapies, including liquid nitrogen cryotherapy, topical dinitrochlorobenzene, topical podophyllin, and intralesional interferon-alfa injections. Approximately 1 year after starting a potent protease inhibitor-containing antiretroviral regimen, the patient's recalcitrant cutaneous warts markedly diminished in size, even though the patient did not receive any specific therapy for the warts after starting aggressive antiretroviral therapy. The patient continued on a potent protease inhibitor-containing antiretroviral regimen and, approximately 2 years later, the warts completely resolved. Our patient's dramatic clinical improvement of cutaneous HPV infection that followed protease inhibitor-containing antiretroviral therapy provides a clear-cut example that protease inhibitor-containing combination antiretroviral therapy can produce significant clinical benefit.

Large papillomatous lesions clinically resembling verrucous carcinoma may be caused by viruses other than human papillomavirus. We report a case of recurrent vegetations covering the entire vulva in a pregnant patient with common variable immunodeficiency. Herpes simplex virus was recovered from these lesions. The patient did not respond to intravenous acyclovir, but her lesions dramatically healed with two courses of intravenous foscarnet. Repeated biopsies may prove necessary in cases such as this to ensure proper diagnoses.

We performed an immunohistochemical analysis of a skin lesion from a patient with AIDS who had borderline tuberculoid Hansen's disease. We also evaluated other laboratory features and performed peripheral blood flow cytometric analysis. The in situ immunologic response to Mycobacterium leprae was minimally affected by concomitant infection and immunosuppression by HIV. The skin demonstrated the typical characteristics of borderline tuberculoid lesions. These results indicate that although a patient with HIV infection may have laboratory evidence typical of the immunosuppression seen in AIDS, the immunologic response to M. leprae is essentially unchanged.

Patients infected with HIV are susceptible to many opportunistic fungal infections. Cryptococcus neoformans infection is particularly common in patients with AIDS. We describe a patient with disseminated cryptococcosis resembling molluscum contagiosum and review the typical cutaneous manifestations of disseminated cryptococcosis. A synopsis of case reports in the English literature is also presented.

The severe immunosuppression associated with HIV infection increases susceptibility to opportunistic fungi. We describe a primary gangrenous cutaneous infection caused by Rhizopus arrhizus in an HIV-infected intravenous narcotic user. In addition, we review nine reported cases of zygomycosis in HIV-infected patients and discuss the frequency and outcome of zygomycosis in HIV infection. Eight of 10 patients were intravenous drug users. Cutaneous infection occurred in four patients. Another case was associated with drug-induced neutropenia. With treatment, 60% of the patients recovered. HIV-induced immunosuppression rarely predisposes to zygomycosis except in intravenous drug users or persons with other risk factors for this fungal infection.

Background : In patients with psoriasis and human immunodeficiency virus type 1 (HIV-1) infection, therapeutic options may be limited by their potential immunosuppressive effects. UVB radiation can activate HIV-1 gene expression in transgenic mice and in vitro. It is not known whether this viral activation leads to a clinically significant effect or if these findings can be extrapolated to humans. Objective : This study was performed to evaluate the safety of UVB light treatment in HIV-infected persons. Methods : We prospectively studied the effect of UVB phototherapy on five HIV-infected patients with psoriasis and one with pruritus. A complete blood cell count with differential count, CD4 + and CD8 + T-lymphocyte counts, serum β 2 -microglobulin and HIV-1 p24 antigen were obtained before UVB phototherapy and after 21 and 42 treatments. After every five treatments patients were evaluated for opportunistic infections, and psoriatic involvement was quantified with the Psoriasis Area and Severity Index (PASI). Results : Cumulative UVB doses ranged from 3326 to 43,364 mJ/cm 2 . There were no statistically significant changes in laboratory findings after 21 and 42 treatments. Of three patients without detectable serum levels of HIV-1 p24 antigen before phototherapy, only one became positive after 42 treatments. None of the six subjects had an opportunistic infection or malignancy during phototherapy. The PASI improved in all five patients with psoriasis, and the other patient noticed decreased pruritus. Conclusion : Our results suggest that UVB phototherapy is efficacious in HIV-1-infected patients with UVB-responsive dermatoses and is not associated with short-term changes in immune function.

Cutaneous infections are a significant cause of morbidity in solid organ recipients. These infections may be complex with multiple pathogens occurring in the same lesion. We describe the unusual association of cutaneous Aspergillus and cytomegalovirus (CMV) infections in a liver transplant recipient. Cutaneous CMV infection is rare and often indicates severe systemic involvement, whereas Aspergillus is a frequent cause of opportunistic cutaneous fungal infection. Seven weeks after liver transplantation, our patient had hemorrhagic, eroded plaques develop on his arms. The results of routine histology, immunoperoxidase staining for CMV antibody, and fungal culture revealed coexistent cutaneous Aspergillus flavus and CMV infections. The patient was treated with ganciclovir, amphotericin B, and topical terbinafine cream; however, 2 weeks after the development of the cutaneous lesions, the patient died. (J Am Acad Dermatol 2001;44:370-2.)

Trichosporon Cutaneum is a yeast-like fungus that causes white piedra and onychomycosis. Recently, it has also been recognized as an opportunistic pathogen in immunocompromised hosts. We describe a 64-year-old woman who developed a superficial Trichosporon infection mimicking hand eczema during chemotherapy for her chronic myelocytic leukemia. To our knowledge, no cases of superficial infection like this one have previously been reported. This case suggests that careful examination is required in diagnosing Trichosporon infection in immunocompromised hosts, because the infection can be invasive or unusual in appearance. (J Am Acad Dermatol 2000;42:929-31.)

Background The incidence of pneumocystis pneumonia (PCP), an opportunistic infection caused by Pneumocystis jiroveci , in patients taking immunosuppressive medications for dermatologic indications is unknown. Objective We sought to define the incidence of PCP in patients with dermatologic conditions, to characterize risk factors for PCP development in these patients, to examine PCP prophylaxis practices among dermatologists, and to document adverse effects of PCP prophylaxis medications. Methods We reviewed the medical records of patients taking immunosuppressive medications for longer than 1 month who were treated for dermatologic conditions between 1998 and 2007 at Mayo Clinic, Rochester, MN. Results Of 198 patients meeting inclusion criteria (150 [75.8%] of whom received no PCP prophylaxis), one patient (0.5% and 0.7%, respectively) had PCP that developed during the follow-up period. In this patient, a 94-year-old woman with bullous pemphigoid, severe interstitial pulmonary fibrosis, aortic stenosis, and hypoalbuminemia, PCP developed within 7 months of diagnosis and was treated with methotrexate and prednisone. She had not received PCP prophylaxis. Only 6 patients (3%) with dermatology as their primary service received PCP prophylaxis. Overall, rates of adverse effects with PCP prophylaxis were low. Limitations The study design was retrospective. Low rates of PCP precluded our development of concrete PCP prophylaxis guidelines. Conclusions Results did not support routine administration of PCP prophylaxis in all patients taking immunosuppressive medications. When prescribing immunosuppressive medications for dermatologic indications, physicians should consider PCP prophylaxis on a case-by-case basis.

Chronic herpesvirus infections are common in patients infected with HIV. Atypical skin lesions secondary to long-standing varicella-zoster virus (VZV) infection have been reported. We present a case of an AIDS patient with a chronic VZV infection that simulated a basal cell carcinoma. Histologic examination and immunohistochemistry confirmed the presence of the virus in the follicular epithelium. In the immunocompromised patient, biopsies should be performed on all suspicious lesions because medically-treatable infections may take on the appearance of malignancy.

In immunocompromised patients, warts occur frequently and can be extensive. We describe a 24-year-old patient with severe therapy-resistant warts. In addition to human papillomavirus infection, he had chronic sinusitis, candidiasis, and atopic dermatitis. Anergy to delayed-type hypersensitivity skin test reaction, significant CD4 lymphopenia, and diminished in vitro T-cell proliferative response and interferon-γ production indicated a deficiency of cellular immunity. Extremely low concentrations of serum IgM and IgG2 and a severe deficiency of in vitro IgM production pointed also to a humoral immunodeficiency syndrome. This case represents a combination of cellular and humoral immunodeficiencies that has not been previously described in association with warts. (J Am Acad Dermatol 1997;36:850-2.)

We sought to evaluate and review the clinical and histopathologic features of cutaneous infections caused by the environmental opportunistic fungus Alternaria observed in transplant recipients.We conducted a retrospective study of cases of cutaneous alternariosis in transplant recipients given a diagnosis in 3 hospitals in Catalonia, Spain, between 1991 and 2001. The clinical and evolution features were reviewed. A panel of histopathologic features was evaluated by two independent observers in all cutaneous biopsy specimens.In all, 9 transplant recipients (8 men and 1 woman) presenting opportunistic cutaneous alternariosis were studied. The patients were 4 renal, 2 cardiac, 1 liver, and 2 lung transplant recipients. All patients were treated with different immunosuppressive therapeutic regimes. The lesions were solitary (3 patients) or multiple grouped (6 patients): papules (4 patients), plaques (5 patients), inflammatory nodules (2 patients), and recurrent cellulitis with secondary ulceration (1 patient), mainly located on the lower extremities. No extracutaneous involvement was detected. A previous traumatic event was recorded in two patients. A total of 12 cutaneous biopsy specimens were reviewed. Biopsy specimens from early lesions (3 months evolution) were often characterized by the presence of epidermal changes (3/6 pseudoepitheliomatous hyperplasia; 50%), a diffuse dermal mixed inflammatory infiltrate of lymphocytes, plasma cells, histiocytes, neutrophils, and giant cells, and rare and focal granuloma formation. Dermal abscess or necrotizing folliculitis was occasionally noted. In biopsy specimens from more advanced lesions (3 months evolution), the presence of a granulomatous inflammatory infiltrate was a constant feature. Suppurative granulomas (2/6; 33%) and sarcoidlike granulomas (2/6; 33%) were noted. In all biopsy specimens, fungal structures with a typical round-to-oval, thick refractile wall were identified.Different clinical and histopathologic patterns can be noted in cutaneous alternariosis. Clinically the lesions manifest as solitary or grouped papules, plaques, or nodules mainly involving the lower extremities. Histologically, a relationship between the evolution of the cutaneous lesions and granuloma formation is detected. An increased awareness regarding the clinical and histopathologic features of cutaneous alternariosis in transplant recipients is important to achieve early detection and treatment.

Cutaneous manifestations of miliary tuberculosis are rare. We report two patients with previously unknown advanced human immunodeficiency virus (HIV) infection, who presented with respiratory collapse and an erythematous papulopustular skin eruption. Skin biopsies demonstrated focal dermal microabscess in one patient, and a subcorneal vesicle with an underlying dermal microabscess in the other. Despite the lack of granulomatous inflammation, acid-fast bacilli (AFB) and Fite stains demonstrated numerous acid-fast bacilli, and Mycobacterium tuberculosis was subsequently isolated in either skin and/or sputum cultures. Pulmonary involvement was present in both cases, but was sufficiently diffuse and atypical so as not to be specific for tuberculosis upon initial clinical and radiographic examination. Our two cases illustrate the importance of careful skin examination in patients with HIV infection, since cutaneous dissemination can be an easily overlooked sign of miliary tuberculosis.

We describe the first case of rickettsialpox in a patient infected with HIV. Immunohistochemical staining of biopsied lesions showed a relatively large number of rickettsiae within the papulovesicular rash. Rickettsialpox is easily treated and may resemble more serious cutaneous eruptions in patients infected with HIV. This diagnosis should be considered in immunocompromised city-dwellers, with fever and a papulovesicular rash.

Cutaneous involvement with disseminated histoplasmosis occasionally occurs in patients infected with the human immunodeficiency virus. We describe a profoundly immunocompromised patient with acquired immunodeficiency syndrome who had concomitant psoriasis, seborrheic dermatitis, and disseminated histoplasmosis, each with similar features. Findings of a skin biopsy specimen from a lesion on the forehead showed an infiltrate of histiocytes filled with Histoplasma capsulatum . In disseminated histoplasmosis involvingthe skin, lesions may have features more characteristic of a papulosquamous dermatosis than an infectious disease. In patients infected with human immunodeficiency virus, especially those with low numbers of CD4+ cells, serious infectious diseases may have unusual features and may assume the appearance of concomitant inflammatory diseases.

Tumor necrosis factor–alfa levels are linked to disease severity in patients with inflammatory conditions, such as psoriasis. Inhibitors of this cytokine are commonly used with significant success in the treatment of such inflammatory disorders. Their use, however, can be plagued by infectious complications. An awareness of potential infections associated with these therapies is critical in order to maximize preventive efforts both before and during therapy. This review provides a guide for dermatologists caring for patients in need of this type of biologic therapy to preemptively address the infectious risks. Part II of this continuing medical education article reviews recommended screening methods for patients undergoing evaluations for tumor necrosis factor inhibitor therapy for psoriasis or other dermatologic diseases, and discusses possible prophylactic strategies to use, including the appropriate use of immunizations.

Background: Numerous etiologic agents of subcutaneous phaeohyphomycosis have been reported. Colletotrichum spp, common plant pathogens, have been reported as a cause of ocular keratomycosis, but only one previous case of cutaneous disease (hyalohyphomycosis) has been attributed to this genus. Objective: Our purpose was to describe 3 cases of subcutaneous phaeohyphomycosis due to Colletotrichum spp occurring in patients undergoing chemotherapy for hematologic malignancies. Methods: Three cases of Colletotrichum -induced phaeohyphomycosis are reviewed. The clinical and histologic features of this infection are presented, the antifungal susceptibilities are reported, and treatment options are discussed. Results: We describe the first report in which C coccodes and C gloeosporioides are implicated as etiologic agents of subcutaneous phaeohyphomycosis. Despite treatment, one patient died after the onset of visceral fungal disease. Conclusion: Colletotrichum spp may cause life-threatening phaeohyphomycosis in immunosuppressed patients. Prompt recognition and intervention with surgical and antifungal treatment may result in decreased morbidity and mortality associated with these infections. (J Am Acad Dermatol 2001;45:56-61.)

Clinical presentations of varicella-zoster virus (VZV) infection may vary widely among healthy and immunocompromised patients. In addition, the recurrence of VZV infection with cutaneous manifestations in both of these populations is more common than was once believed. Most cases of verrucous varicella infection have been reported in patients with documented immunosuppression (most commonly HIV/AIDS). We present an unusual case of persistent verrucous varicella, which was the initial manifestation of HIV infection, in a previously "healthy" 3-year-old girl with a strong family history of Wiskott-Aldrich Syndrome. Current research, therapeutic options, and differential diagnoses with regard to VZV infection are briefly reviewed.

Infections with mycobacteria are of importance in the differential diagnosis of skin lesions in immunocompromised patients. We report the case of a human immunodeficency virus (HIV)-infected patient who presented with an annular plaque as cutaneous manifestation of Mycobacterium haemophilum. Improvement of the immunologic status is important for successful treatment. Complete resolution was only observed when the antimycobacterial therapy was combined with antiretroviral therapy.

Ecthyma gangrenosum is the cutaneous manifestation of Pseudomonas aeruginosa septicemia, typically affecting immunosuppressed patients, particularly those with neutropenia. Association with HIV disease has been rarely reported. We describe an unusual presentation of solitary ecthyma gangrenosum on the face of a non-neutropenic patient with AIDS. (J Am Acad Dermatol 1999;41:840-1.)

A 31-year-old man presented with acute pain in his left arm and hemorrhagic vesicles that followed his left 8th cervical nerve. A diagnosis of herpes zoster was made, and the patient was treated with valacyclovir. He refused testing for antibodies to HIV because he denied being at risk. Two months later he returned with postherpetic neuralgia and postherpetic hyperhidrosis in the distribution of the vesicles, which had since resolved. Serology for HIV at this visit was positive, and the patient admitted to having sexual relations with prostitutes. Six months later the patient was being treated with triple antiretroviral therapy, and all signs and symptoms of postherpetic zoster had resolved. This case report documents the need for HIV testing in patients with unusual presentations of herpes zoster even if they initially deny being at risk. (J Am Acad Dermatol 1999;41:119-21.)

Noncontiguous multidermatomal herpes zoster is very rare in both immunocompetent and immunocompromised persons. Most of the reported cases have been limited to 2 noncontiguous dermatomes. This unique presentation has been referred to as zoster duplex unilateralis or bilateralis, depending on whether one or both halves of the body are involved. Granulomatous dermatitis at sites of herpes zoster scars, a rare isotopic response, has only been reported in persons with contiguous dermatomes of zoster. We describe an immunocompromised patient who developed herpes zoster in 7 disparate dermatomes. Three months after resolution of the zoster, the patient developed a granulomatous dermatitis in a zosteriform distribution at the sites of previous infection.

Sporotrichosis most commonly presents as a localized, lymphocutaneous infection that follows trauma, such as an injury from a rose thorn. In patients infected with HIV, it may be widespread and disseminated. We describe a patient with AIDS who developed disseminated sporotrichosis, a rare opportunistic fungal infection that may affect these patients. The condition remained undiagnosed because of failure to recognize characteristic histopathologic findings and failure of clinicians to interface closely with the microbiology laboratory. The condition was difficult to treat, requiring systemic administration of amphotericin. While localized sporotrichosis is an innocuous disorder that responds well to therapy, in immunocompromised hosts, it is potentially life-threatening and may require prolonged therapy with potentially toxic medications such as amphotericin B. It is important that clinicians be aware of the presentation of this unusual opportunistic infection and that they maintain close communication with pathology and clinical microbiology laboratories to ensure that proper stains and cultures are performed to avoid potential misdiagnosis. (J Am Acad Dermatol 1999;40:350-5.)

Background: New opportunistic fungal infections cause significant morbidity and death in patients who are severely immunocompromised. Cutaneous lesions may be the first clinical manifestation and give the clue to early diagnosis. Objective: The purpose of this study was to describe the clinical and histologic manifestations of Paecilomyces lilacinus infection in patients who are severely immunosuppressed. Methods: Within a 3-month period, we observed 5 patients with allogenic bone marrow transplantation and 4 patients with aplasia after chemotherapy for hematologic malignancies who developed skin eruptions caused by invasive P lilacinus . Results: The skin lesions began in 7 cases during or shortly after recovery of pancytopenia. Most of the skin lesions were located on the lower extremities. The cutaneous manifestations were highly variable including erythematous macules, nodules, pustules, vesicular lesions, and necrotic crusts. In 3 biopsy specimens, histologic examination revealed hyphae in periodic acid–Schiff–stained sections. In all patients P lilacinus was isolated from skin tissue samples. P lilacinus was identified from all lesions either by skin biopsy or needle aspiration from clinically evident lesions. In 3 additional cases, the patient's hands were colonized without skin lesions. The source of the epidemic outbreak was finally traced down to several contaminated lots of a topical moisturizing agent. Two patients died; one patient had septic lesions in the eye and kidney as the result of P lilacinus . Conclusion: Clinical and histologic findings of P lilacinus infection with cutaneous manifestations in patients who are severely immunosuppressed are summarized. P lilacinus is resistant to all systemic antimycotics available, and in general, recovery of immunosuppression is necessary to eradicate the mold. Contaminated topical dermatologic agents should be included in the differential diagnosis as a source for severe epidemic cutaneous manifestations of fungal infection in patients who are severely immunosuppressed. This fact implies that additional safety guidelines are necessary for topical dermatologic agents used for patients who are severely immunosuppressed. (J Am Acad Dermatol 1998;39:401-9.)

From the Department of Dermatology, Yale University School of Medicine. Reprint requests: Leonard M. Milstone, MD, Professor of Dermatology, Yale University School of Medicine, Department of Dermatology, 333 Cedar St, 501 LCI, New Haven, CT 065208059. J Am Acad Dermatol 1998;39:276-8. Copyright © 1998 by the American Academy of Dermatology, Inc. 0190-9622/98/$5.00 + 0 16/54/90382 Low-dose methotrexate is widely used in the treatment of rheumatoid arthritis, and in psoriasis and other cutaneous diseases.1,2 The complication rate is low, with the benefits of its use far outweighing the risks.3 However, there have been a number of opportunistic infections associated with the increasing use of methotrexate for chronic inflammatory conditions.4 We report a case of Pneumocystis carinii pneumonia in a man treated with methotrexate for pityriasis rubra pilaris (PRP). We also review the other reported cases of P. carinii pneumonia associated with low-dose methotrexate therapy.

In 1883, Majocchi first described an intracutaneous or subcutaneous granulomatous inflammation arising as a result of local invasion by a dermatophyte, which he called granuloma tricofitico. t The most common cause is Trichophyton rubrum. 2 Two types of Majocchi's granuloma have been described, a perifollicular type secondary to trauma and a subcutaneous nodular type in immunocompromised hosts.2,3 We describe two

A patient receiving long-term immunosuppressive treatment of systemic lupus erythematosus developed multiple large painful ulcers on her upper body. Histologic analysis showed cytopathic changes typical of cytomegalovirus infection that was confirmed by immunoperoxidase staining and polymerase chain reaction analyses. Treatment with ganciclovir and foscarnet resulted in clinical resolution. No recurrence was evident 6 months later.

gistic effect on the development of xanthomas. The fact that patients who were treated with compression stockings showed clearing of xanthomas adds support to the belief that the occurrence of xanthomas may be, at least in part, a pressure phenomenon] , 8 There are associations reported between primary lymphedema and cardiopulmonary congenital abnormalities. 1-3 However, to our knowledge this is the fu'st reported case with the added presence of xanthomas.

Primary cutaneous mucormycosis is a rare opportunistic fungal infection that is usually limited to the skin. We describe a primary cutaneous Rhizopus infection occurring at a site occluded by a sterile adhesive dressing in which the disease was viscerally disseminated at the time of diagnosis. Mucormycosis should be considered in all ecthyma-like lesions in immunocompromised patients. It may be rapidly diagnosed by examination of hematoxylin-eosin and PAS-stained sections of the eschar base and a culture of a leading edge tissue aspirate. We review 21 cases of primary cutaneous mucormycosis in children and compare them with the present case.

Bacillary angiomatosis (BA), an infection caused by a gram-negative rod, can be a multi-organ disease. The usual causative organism, Bartonella (formerly Rochalimaea ) hensalae , has only recently been identified. Bartonella quintana has also been shown to cause some cases of cutaneous BA. We describe a patient with widespread cutaneous BA with probable bone involvement and a large fungating mass.

Trichophyton rubrum usually causes disease in keratinized epithelial structures such as hairs and nails, 1 but rarely it may invade the dermis, particularly in immunocompromised patients. 2-5 However, deep dermatophytosis from T. rubrum has not been previously described in a patient with AIDS. We describe a patient with AIDS who also had multiple noduloulcerative skin lesions caused by invasion of the reticular dermis by T. rubrum.

Superficial fungal infections are common in patients with HIV infection. These infections may be widespread or have an unusual form or suucture. 1 Scutula are yellow cup-shaped crusts classically present in favus of the scalp. 2 To our knowledge, their presence on glabrous skin in a patient with AIDS has not been reported previously.

Five cases of Norwegian or keratotic scabies in HIV-positive patients are described. One of these patients was the source of an outbreak in a hospital, ultimately involving 72 persons. Three of our patients had a markedly pruritic eruption. This is unusual in crusted scabies in which pruritus is usually slight or absent. Two of the five patients had unusual CD4 counts of more than 200 cells per cubic millimeter. All our patients responded to lindane and keratolytic agents. When generalized papular, crusted, or eczematoid lesions are observed in HIV-positive patients, particularly if the CD4 count is less than 200/mm3, scabies should be included in the differential diagnosis.

Bacillus piliformis is a long, rod-shaped bacterium that has never been grown in cell-free medium and whose taxonomic classification is uncertain. B. piliformis is the causative agent of Tyzzer's disease, which is frequently reported in laboratory, wild, and domesticated animals. The spectrum and severity of this disease is wide in animals. Although many infections are rapidly fatal, subclinical infections are also common. To date, there have been no reports of B. piliformis infection in human beings, although elevated antibody levels have been reported in pregnant women. We describe the first case of human B. piliformis infection, in a man with HIV-1 infection and chronic, localized, crusted verrucous lesions. The diagnosis was confirmed by ribosomal RNA sequencing. The spectrum of organisms leading to infection and the spectrum of diseases caused by these organisms continue to expand, as new infections are identified and as patients with HIV-1 live longer with more severe immune suppression. The extreme difficulty in culturing B. piliformis and the lack of clinical and histopathologic experience with this organism in human beings mean that B. piliformis is potentially another infections agent to be considered in human beings. Also, when an infectious organism is a strong clinical consideration, silver stains may be of use when results of routine bacterial staining are negative.

Sporotrichosis is caused by the dimorphic fungus Sporothrix schenckii. The organism can be found in soil and may be associated with sphagnum moss.l-ll Infection is generally a result of implantation into the subcutaneous tissue by contaminated organic material. Agricultural workers are therefore most at risk for infection.12 The disease is generally limited to the skin and subcutaneous tissues. Disseminated sporotrichosis is generally associated with immunodeficiency; in these instances, disseminated infection may result from inhaling infectious f&gal particles from the soil or from reactivation of old disease. Although sporotrichosis is not a common opportunistic infection in HIV-infected patients, more cases are being reported. 13-19 We describe an HIV-infected patient with disseminated sporotrichosis who was exposed to sphagnum moss while cultivating bonsai trees.

Disseminated cryptococcosis is a life-threatening infection with cutaneous dissemination in 10% to 20% of cases. We describe seven patients with disseminated cryptococcosis with variable cutaneous manifestations. AIDS was a predisposing factor in six patients. Cutaneous presentations included a draining sinus tract, verrucous nodules, molluscum-like lesions and erythematous, indurated plaques. Histologically, all lesions revealed numerous encapsulated cryptoccocal organisms in a gelatinous pattern, highlighted with periodic acid-Schiff, mucicarmine, and methenamine silver stains. The patients responded variably to treatment with amphotericin B, flucytosine, and fluconazole.

We describe a patient with cutaneous T-cell lymphoma in whom persistent, painless, ecthymatous nodules developed as a result of a varicella-zoster virus infection. The localized infection occurred without a vesicular stage. Ultrastructural studies revealed a lack of epidermal involvement and massive varicella-zoster virus replication within endothelial cells, leading to an obliterative vasculitis. This suggests direct infection of dermal vessels from adjacent nerves, bypassing the epidermis, which is usually infected first in the classic infectious pathway during varicella-zoster virus reactivation from sensory nerves.

Pyoderma gangrenosum has previously been reported in four patients with HIV infection. We describe here the case of a fifth HIV-infected patient with pyoderma gangrenosum and review the characteristics of the four previously reported cases.

Mycobacterium haemophilum, an atypical mycobacterium first identified in 1978, infects primarily immunocomprornised patients. Skin lesions caused by this organism are occurring with increasing frequency in patients with AIDS. Despite a variety of recommendations, optimal treatment remains unclear. We report the first case of curative surgical excision of an M. haemophilum cutaneous ulcer without adjunct chemotherapy.