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Erythematous Abdominal Nodule
The Diagnosis: Foreign Body Reaction With Sinus Tract
A delayed foreign body reaction is a rare complication of retained temporary pacing wires following cardiovascular surgery. These epicardial pacing wires are important for the management of postoperative arrhythmia and normally are removed by external traction after normal rhythm has been re-established. However, it is not uncommon for these wires to be cut at the skin surface in the setting of difficult removal, as retained pacing wires generally are viewed as benign.1 These reactions often take years after placement of the pacing wire to present themselves and most often resolve with either complete removal of the wire or resection of the distal end.2
Our patient was referred to dermatology and underwent a shave biopsy. Results were consistent with chronic inflammatory granulation tissue. Bacterial tissue culture grew Staphylococcus epidermidis. Cultures for acid-fast bacilli and fungi were negative. The patient was referred to cardiothoracic surgery. Computed tomography identified a retained temporary pacing wire extending to the base of the lesion. The lesion was excised and the distal aspect of the pacing wire was removed, which resulted in resolution of the nodule.
The differential diagnosis includes pyoderma gangrenosum, nodular basal cell carcinoma, Sister Mary Joseph nodule, and pyogenic granuloma. Pyoderma gangrenosum is a neutrophilic dermatosis that presents as a rapidly progressing, painful, necrotic ulcer. It is classically associated with inflammatory bowel disease and other systemic diseases but also can occur in isolation.3
Nodular basal cell carcinomas often develop in chronically sun-exposed areas of the body. Morphologically, they present as pink, pearl appearing papules with rolled borders and overlying arborizing telangiectasia. Nodular basal cell carcinomas may present with recurrent bleeding but typically do not have continuous drainage.4
Sister Mary Joseph nodule represents a periumbilical lymphatic metastasis from an underlying (usually intra-abdominal) malignancy. It typically presents as an umbilical or periumbilical nodule measuring 0.5 to 15 cm in diameter. The nodules often are painful and discharge a serous fluid. It is estimated that they are present in 1% to 3% of cases of abdominopelvic malignancy, but Sister Mary Joseph nodules also have been reported in several other types of solid organ tumors.5
Pyogenic granuloma is a benign vascular lesion that classically develops rapidly over the course of a few weeks. It often presents as a single red, moist, friable papule with a collarette of scale and frequently is associated with pain, bleeding, and ulceration. Keratinized skin or mucosa can be affected, and pyogenic granuloma is most common in children and young adults.6
- Chung DA, Smith EE. Delayed presentation of foreign body reaction secondary to retained pacing wires. Ann Thorac Surg. 1998;66:550-551.
- Gentry WH, Hassan AA. Complications of retained epicardial pacing wires (an unusual bronchial foreign body. Ann Thorac Surg. 1993;56:1391-1393.
- Ahn C, Negus D, Huang W. Pyoderma gangrenosum: a review of pathogenesis and treatment. Expert Rev Clin Immunol. 2018;14:225-233.
- Tanese K. Diagnosis and treatment of basal cell carcinoma. Curr Treat Options Oncol. 2019;20:13
- Tso S, Brockley J, Recica H, et al. Sister Mary Joseph's nodule: an unusual but important physical finding characteristic of widespread internal malignancy. Br J Gen Pract. 2013;63:551-552.
- Mashiah J, Hadj-Rabia S, Slodownik D, et al. Effectiveness of topical propranolol 4% gel in the treatment of pyogenic granuloma in children. J Dermatol. 2019;46:245-248.
The Diagnosis: Foreign Body Reaction With Sinus Tract
A delayed foreign body reaction is a rare complication of retained temporary pacing wires following cardiovascular surgery. These epicardial pacing wires are important for the management of postoperative arrhythmia and normally are removed by external traction after normal rhythm has been re-established. However, it is not uncommon for these wires to be cut at the skin surface in the setting of difficult removal, as retained pacing wires generally are viewed as benign.1 These reactions often take years after placement of the pacing wire to present themselves and most often resolve with either complete removal of the wire or resection of the distal end.2
Our patient was referred to dermatology and underwent a shave biopsy. Results were consistent with chronic inflammatory granulation tissue. Bacterial tissue culture grew Staphylococcus epidermidis. Cultures for acid-fast bacilli and fungi were negative. The patient was referred to cardiothoracic surgery. Computed tomography identified a retained temporary pacing wire extending to the base of the lesion. The lesion was excised and the distal aspect of the pacing wire was removed, which resulted in resolution of the nodule.
The differential diagnosis includes pyoderma gangrenosum, nodular basal cell carcinoma, Sister Mary Joseph nodule, and pyogenic granuloma. Pyoderma gangrenosum is a neutrophilic dermatosis that presents as a rapidly progressing, painful, necrotic ulcer. It is classically associated with inflammatory bowel disease and other systemic diseases but also can occur in isolation.3
Nodular basal cell carcinomas often develop in chronically sun-exposed areas of the body. Morphologically, they present as pink, pearl appearing papules with rolled borders and overlying arborizing telangiectasia. Nodular basal cell carcinomas may present with recurrent bleeding but typically do not have continuous drainage.4
Sister Mary Joseph nodule represents a periumbilical lymphatic metastasis from an underlying (usually intra-abdominal) malignancy. It typically presents as an umbilical or periumbilical nodule measuring 0.5 to 15 cm in diameter. The nodules often are painful and discharge a serous fluid. It is estimated that they are present in 1% to 3% of cases of abdominopelvic malignancy, but Sister Mary Joseph nodules also have been reported in several other types of solid organ tumors.5
Pyogenic granuloma is a benign vascular lesion that classically develops rapidly over the course of a few weeks. It often presents as a single red, moist, friable papule with a collarette of scale and frequently is associated with pain, bleeding, and ulceration. Keratinized skin or mucosa can be affected, and pyogenic granuloma is most common in children and young adults.6
The Diagnosis: Foreign Body Reaction With Sinus Tract
A delayed foreign body reaction is a rare complication of retained temporary pacing wires following cardiovascular surgery. These epicardial pacing wires are important for the management of postoperative arrhythmia and normally are removed by external traction after normal rhythm has been re-established. However, it is not uncommon for these wires to be cut at the skin surface in the setting of difficult removal, as retained pacing wires generally are viewed as benign.1 These reactions often take years after placement of the pacing wire to present themselves and most often resolve with either complete removal of the wire or resection of the distal end.2
Our patient was referred to dermatology and underwent a shave biopsy. Results were consistent with chronic inflammatory granulation tissue. Bacterial tissue culture grew Staphylococcus epidermidis. Cultures for acid-fast bacilli and fungi were negative. The patient was referred to cardiothoracic surgery. Computed tomography identified a retained temporary pacing wire extending to the base of the lesion. The lesion was excised and the distal aspect of the pacing wire was removed, which resulted in resolution of the nodule.
The differential diagnosis includes pyoderma gangrenosum, nodular basal cell carcinoma, Sister Mary Joseph nodule, and pyogenic granuloma. Pyoderma gangrenosum is a neutrophilic dermatosis that presents as a rapidly progressing, painful, necrotic ulcer. It is classically associated with inflammatory bowel disease and other systemic diseases but also can occur in isolation.3
Nodular basal cell carcinomas often develop in chronically sun-exposed areas of the body. Morphologically, they present as pink, pearl appearing papules with rolled borders and overlying arborizing telangiectasia. Nodular basal cell carcinomas may present with recurrent bleeding but typically do not have continuous drainage.4
Sister Mary Joseph nodule represents a periumbilical lymphatic metastasis from an underlying (usually intra-abdominal) malignancy. It typically presents as an umbilical or periumbilical nodule measuring 0.5 to 15 cm in diameter. The nodules often are painful and discharge a serous fluid. It is estimated that they are present in 1% to 3% of cases of abdominopelvic malignancy, but Sister Mary Joseph nodules also have been reported in several other types of solid organ tumors.5
Pyogenic granuloma is a benign vascular lesion that classically develops rapidly over the course of a few weeks. It often presents as a single red, moist, friable papule with a collarette of scale and frequently is associated with pain, bleeding, and ulceration. Keratinized skin or mucosa can be affected, and pyogenic granuloma is most common in children and young adults.6
- Chung DA, Smith EE. Delayed presentation of foreign body reaction secondary to retained pacing wires. Ann Thorac Surg. 1998;66:550-551.
- Gentry WH, Hassan AA. Complications of retained epicardial pacing wires (an unusual bronchial foreign body. Ann Thorac Surg. 1993;56:1391-1393.
- Ahn C, Negus D, Huang W. Pyoderma gangrenosum: a review of pathogenesis and treatment. Expert Rev Clin Immunol. 2018;14:225-233.
- Tanese K. Diagnosis and treatment of basal cell carcinoma. Curr Treat Options Oncol. 2019;20:13
- Tso S, Brockley J, Recica H, et al. Sister Mary Joseph's nodule: an unusual but important physical finding characteristic of widespread internal malignancy. Br J Gen Pract. 2013;63:551-552.
- Mashiah J, Hadj-Rabia S, Slodownik D, et al. Effectiveness of topical propranolol 4% gel in the treatment of pyogenic granuloma in children. J Dermatol. 2019;46:245-248.
- Chung DA, Smith EE. Delayed presentation of foreign body reaction secondary to retained pacing wires. Ann Thorac Surg. 1998;66:550-551.
- Gentry WH, Hassan AA. Complications of retained epicardial pacing wires (an unusual bronchial foreign body. Ann Thorac Surg. 1993;56:1391-1393.
- Ahn C, Negus D, Huang W. Pyoderma gangrenosum: a review of pathogenesis and treatment. Expert Rev Clin Immunol. 2018;14:225-233.
- Tanese K. Diagnosis and treatment of basal cell carcinoma. Curr Treat Options Oncol. 2019;20:13
- Tso S, Brockley J, Recica H, et al. Sister Mary Joseph's nodule: an unusual but important physical finding characteristic of widespread internal malignancy. Br J Gen Pract. 2013;63:551-552.
- Mashiah J, Hadj-Rabia S, Slodownik D, et al. Effectiveness of topical propranolol 4% gel in the treatment of pyogenic granuloma in children. J Dermatol. 2019;46:245-248.
A 71-year-old man presented with an inflamed erythematous papule on the right subcostal region of 12 months’ duration. It began as a small pimplelike bump that slowly enlarged. The patient did not report any pain or pruritus, but the lesion intermittently drained purulent fluid. The patient had a pacemaker and a history of severe aortic stenosis for which he underwent bioprosthetic aortic valve repair approximately 3 years prior to presentation. His postoperative course was complicated by sternal wound infection and sepsis, prompting surgical replacement of the graft and the pacemaker. He then developed aortitis secondary to bacterial endocarditis with multiple associated septic emboli and is now on lifelong levofloxacin and minocycline therapy. Physical examination revealed a 1.5-cm, erythematous, soft, protuberant nodule with surrounding skin dimpling on the right subcostal region adjacent to a well-healed surgical scar. Approximately 1 to 2 mL of purulent fluid was expressed.
Partially Blanchable Violaceous Lesions in an AIDS Patient
The Diagnosis: Eruptive Disseminated Kaposi Sarcoma
There are 5 types of Kaposi sarcoma (KS): classic KS, African cutaneous KS, African lymphadenopathic KS, AIDS-related KS, and immunosuppression-associated KS. Immunosuppression-associated KS can occur in the setting of lymphoma or in conjunction with immunosuppressive therapy related to organ transplants and long-term corticosteroid treatment.1,2 Kaposi sarcoma associated with highly active antiretroviral therapy–induced immune reconstitution inflammatory syndrome also may occur.3
The possible causes of the manifestation of KS in our patient were 2-fold: (1) AIDS associated given the patient’s CD4 lymphocyte count of 7 cells/mm3, and (2) iatrogenic secondary to drug-induced immunosuppression that was temporally induced by 2 sustained periods of intravenous dexamethasone for cerebral edema in the setting of primary central nervous system lymphoma. It is unlikely that our patient experienced immune reconstitution inflammatory syndrome–induced KS, as the dysphagia interfered with the ability to take antiretroviral therapy during hospitalization. In patients who have experienced KS in the setting of steroid use or organ transplantation, KS lesions spontaneously improved or completely regressed several months after immunosuppression reduction or removal.1,2,4
Clinically and morphologically, our patient also clearly demonstrated the occasionally seen striking manifestation of perilesional, ecchymotic-appearing or bruiselike halos surrounding the KS lesions (Figure).
The initial differential diagnosis included hemorrhagic diathesis but later included KS in the setting of AIDS and immunosuppressive therapy with dexamethasone, bacillary angiomatosis, and cutaneous lymphoma. A biopsy of one of the cutaneous lesions confirmed the diagnosis of KS.
Three standard treatments of primary central nervous system lymphoma currently exist: radiation therapy, intrathecal and/or intraventricular chemotherapy, and steroid therapy.5 Given the patient’s risk for opportunistic infections and immunodeficient state, the medical team was constrained in its treatment options, as all of the therapies would further weaken the patient’s immune system.
Treatment of KS can be local and/or systemic based on disease stage, progression, distribution, clinical type, and immune status.6,7 Our patient had generalized cutaneous KS covering more than 50% of the body, thus making local treatments such as radiation therapy, cryotherapy, intralesional chemotherapy with vincristine or vinblastine, excision, laser therapy, or alitretinoin gel impractical. Single- or multiple-agent systemic treatment options for disseminated cutaneous disease with or without internal organ involvement may include liposomal anthracyclines, paclitaxel, gemcitabine, vinblastine, vincristine, bleomycin, etoposide, and interferon-alfa.6,7 Potent combination antiretroviral therapy is the mainstay for treatment of AIDS-associated KS.8
- Nassar D, Schartz NEC, Bouche C, et al. Kaposi’s sarcoma after long-acting steroids: time until remission and drug washout. Dermatology. 2010;220:159-163.
- Trattner A, Hodak E, David M, et al. The appearance of Kaposi sarcoma during corticosteroid therapy. Cancer. 1993;72:1779-1783.
- Bower M, Nelson M, Young AM, et al. Immune reconstitution inflammatory syndrome associated with Kaposi’s Sarcoma. J Clin Oncol. 2005;23:5224-5228.
- Duman S, Töz H, Aşçi G, et al. Successful treatment of post-transplant Kaposi’s sarcoma by reduction of immunosuppression. Nephrol Dial Transplant. 2002;17:892-896.
- National Cancer Institute. Primary CNS lymphoma treatment. http://www.cancer.gov/cancertopics/pdq/treatment/primary-CNS-lymphoma/Patient/page4. Accessed June 10, 2014.
- Schwartz RA, Micali G, Nasca MR, et al. Kaposi sarcoma: a continuing conundrum. J Am Acad Dermatol. 2008;59:179-206.
- Lee F-C, Mitsuyasu RT. Chemotherapy of AIDS-related Kaposi’s sarcoma. Hematol Oncol Clin North Am. 1996;10:1051-1068.
- Dupont C, Vasseur E, Beauchet A, et al. Long-term efficacy on Kaposi’s sarcoma of highly active antiretroviral therapy in a cohort of HIV-positive patients. AIDS. 2000;14:987-993.
The Diagnosis: Eruptive Disseminated Kaposi Sarcoma
There are 5 types of Kaposi sarcoma (KS): classic KS, African cutaneous KS, African lymphadenopathic KS, AIDS-related KS, and immunosuppression-associated KS. Immunosuppression-associated KS can occur in the setting of lymphoma or in conjunction with immunosuppressive therapy related to organ transplants and long-term corticosteroid treatment.1,2 Kaposi sarcoma associated with highly active antiretroviral therapy–induced immune reconstitution inflammatory syndrome also may occur.3
The possible causes of the manifestation of KS in our patient were 2-fold: (1) AIDS associated given the patient’s CD4 lymphocyte count of 7 cells/mm3, and (2) iatrogenic secondary to drug-induced immunosuppression that was temporally induced by 2 sustained periods of intravenous dexamethasone for cerebral edema in the setting of primary central nervous system lymphoma. It is unlikely that our patient experienced immune reconstitution inflammatory syndrome–induced KS, as the dysphagia interfered with the ability to take antiretroviral therapy during hospitalization. In patients who have experienced KS in the setting of steroid use or organ transplantation, KS lesions spontaneously improved or completely regressed several months after immunosuppression reduction or removal.1,2,4
Clinically and morphologically, our patient also clearly demonstrated the occasionally seen striking manifestation of perilesional, ecchymotic-appearing or bruiselike halos surrounding the KS lesions (Figure).
The initial differential diagnosis included hemorrhagic diathesis but later included KS in the setting of AIDS and immunosuppressive therapy with dexamethasone, bacillary angiomatosis, and cutaneous lymphoma. A biopsy of one of the cutaneous lesions confirmed the diagnosis of KS.
Three standard treatments of primary central nervous system lymphoma currently exist: radiation therapy, intrathecal and/or intraventricular chemotherapy, and steroid therapy.5 Given the patient’s risk for opportunistic infections and immunodeficient state, the medical team was constrained in its treatment options, as all of the therapies would further weaken the patient’s immune system.
Treatment of KS can be local and/or systemic based on disease stage, progression, distribution, clinical type, and immune status.6,7 Our patient had generalized cutaneous KS covering more than 50% of the body, thus making local treatments such as radiation therapy, cryotherapy, intralesional chemotherapy with vincristine or vinblastine, excision, laser therapy, or alitretinoin gel impractical. Single- or multiple-agent systemic treatment options for disseminated cutaneous disease with or without internal organ involvement may include liposomal anthracyclines, paclitaxel, gemcitabine, vinblastine, vincristine, bleomycin, etoposide, and interferon-alfa.6,7 Potent combination antiretroviral therapy is the mainstay for treatment of AIDS-associated KS.8
The Diagnosis: Eruptive Disseminated Kaposi Sarcoma
There are 5 types of Kaposi sarcoma (KS): classic KS, African cutaneous KS, African lymphadenopathic KS, AIDS-related KS, and immunosuppression-associated KS. Immunosuppression-associated KS can occur in the setting of lymphoma or in conjunction with immunosuppressive therapy related to organ transplants and long-term corticosteroid treatment.1,2 Kaposi sarcoma associated with highly active antiretroviral therapy–induced immune reconstitution inflammatory syndrome also may occur.3
The possible causes of the manifestation of KS in our patient were 2-fold: (1) AIDS associated given the patient’s CD4 lymphocyte count of 7 cells/mm3, and (2) iatrogenic secondary to drug-induced immunosuppression that was temporally induced by 2 sustained periods of intravenous dexamethasone for cerebral edema in the setting of primary central nervous system lymphoma. It is unlikely that our patient experienced immune reconstitution inflammatory syndrome–induced KS, as the dysphagia interfered with the ability to take antiretroviral therapy during hospitalization. In patients who have experienced KS in the setting of steroid use or organ transplantation, KS lesions spontaneously improved or completely regressed several months after immunosuppression reduction or removal.1,2,4
Clinically and morphologically, our patient also clearly demonstrated the occasionally seen striking manifestation of perilesional, ecchymotic-appearing or bruiselike halos surrounding the KS lesions (Figure).
The initial differential diagnosis included hemorrhagic diathesis but later included KS in the setting of AIDS and immunosuppressive therapy with dexamethasone, bacillary angiomatosis, and cutaneous lymphoma. A biopsy of one of the cutaneous lesions confirmed the diagnosis of KS.
Three standard treatments of primary central nervous system lymphoma currently exist: radiation therapy, intrathecal and/or intraventricular chemotherapy, and steroid therapy.5 Given the patient’s risk for opportunistic infections and immunodeficient state, the medical team was constrained in its treatment options, as all of the therapies would further weaken the patient’s immune system.
Treatment of KS can be local and/or systemic based on disease stage, progression, distribution, clinical type, and immune status.6,7 Our patient had generalized cutaneous KS covering more than 50% of the body, thus making local treatments such as radiation therapy, cryotherapy, intralesional chemotherapy with vincristine or vinblastine, excision, laser therapy, or alitretinoin gel impractical. Single- or multiple-agent systemic treatment options for disseminated cutaneous disease with or without internal organ involvement may include liposomal anthracyclines, paclitaxel, gemcitabine, vinblastine, vincristine, bleomycin, etoposide, and interferon-alfa.6,7 Potent combination antiretroviral therapy is the mainstay for treatment of AIDS-associated KS.8
- Nassar D, Schartz NEC, Bouche C, et al. Kaposi’s sarcoma after long-acting steroids: time until remission and drug washout. Dermatology. 2010;220:159-163.
- Trattner A, Hodak E, David M, et al. The appearance of Kaposi sarcoma during corticosteroid therapy. Cancer. 1993;72:1779-1783.
- Bower M, Nelson M, Young AM, et al. Immune reconstitution inflammatory syndrome associated with Kaposi’s Sarcoma. J Clin Oncol. 2005;23:5224-5228.
- Duman S, Töz H, Aşçi G, et al. Successful treatment of post-transplant Kaposi’s sarcoma by reduction of immunosuppression. Nephrol Dial Transplant. 2002;17:892-896.
- National Cancer Institute. Primary CNS lymphoma treatment. http://www.cancer.gov/cancertopics/pdq/treatment/primary-CNS-lymphoma/Patient/page4. Accessed June 10, 2014.
- Schwartz RA, Micali G, Nasca MR, et al. Kaposi sarcoma: a continuing conundrum. J Am Acad Dermatol. 2008;59:179-206.
- Lee F-C, Mitsuyasu RT. Chemotherapy of AIDS-related Kaposi’s sarcoma. Hematol Oncol Clin North Am. 1996;10:1051-1068.
- Dupont C, Vasseur E, Beauchet A, et al. Long-term efficacy on Kaposi’s sarcoma of highly active antiretroviral therapy in a cohort of HIV-positive patients. AIDS. 2000;14:987-993.
- Nassar D, Schartz NEC, Bouche C, et al. Kaposi’s sarcoma after long-acting steroids: time until remission and drug washout. Dermatology. 2010;220:159-163.
- Trattner A, Hodak E, David M, et al. The appearance of Kaposi sarcoma during corticosteroid therapy. Cancer. 1993;72:1779-1783.
- Bower M, Nelson M, Young AM, et al. Immune reconstitution inflammatory syndrome associated with Kaposi’s Sarcoma. J Clin Oncol. 2005;23:5224-5228.
- Duman S, Töz H, Aşçi G, et al. Successful treatment of post-transplant Kaposi’s sarcoma by reduction of immunosuppression. Nephrol Dial Transplant. 2002;17:892-896.
- National Cancer Institute. Primary CNS lymphoma treatment. http://www.cancer.gov/cancertopics/pdq/treatment/primary-CNS-lymphoma/Patient/page4. Accessed June 10, 2014.
- Schwartz RA, Micali G, Nasca MR, et al. Kaposi sarcoma: a continuing conundrum. J Am Acad Dermatol. 2008;59:179-206.
- Lee F-C, Mitsuyasu RT. Chemotherapy of AIDS-related Kaposi’s sarcoma. Hematol Oncol Clin North Am. 1996;10:1051-1068.
- Dupont C, Vasseur E, Beauchet A, et al. Long-term efficacy on Kaposi’s sarcoma of highly active antiretroviral therapy in a cohort of HIV-positive patients. AIDS. 2000;14:987-993.
A 37-year-old AIDS patient (CD4 lymphocyte count, 7 cells/mm3 [reference range, 500–1000 cells/mm3]; viral load, >200,000 copies/mL) with a medical history of primary central nervous system lymphoma and recent Salmonella bacteremia was admitted with a 1-week history of dysphagia, generalized weakness, and a 15-lb weight loss over a 2-month period. Medications included prophylaxis with weekly azithromycin and daily atovoquone. The patient had a history of noncompliance with antiretroviral therapy, which included atazanavir sulfate, lamivudine, and zidovudine. One month prior to presentation the patient received a course of intravenous dexamethasone for cerebral edema secondary to mass effect from primary central nervous system lymphoma. On examination the patient was afebrile, cachectic, and in no acute distress. Initially, faint petechial lesions were noted on the torso and upper abdomen. Over the course of 10 days, after reintroduction of intravenous dexamethasone, the patient rapidly and diffusely developed partially blanchable, violaceous macules, patches, papules, and plaques that were most prominent on the trunk and lower extremities. Some of the lesions were surrounded by nonblanchable, yellowish brown, ecchymotic-appearing halos. Lesions spared the oral mucosa, face, and genitalia. There was no evidence of mucocutaneous involvement.
