Cases for Diagnosis
Recent-Onset Bullous Lesions
Lesiones ampollosas de reciente aparición
L. Rodríguez-Lago
, P. Almeida-Martín, L. Borrego-Hernando
Corresponding author
Servicio de Dermatología, Complejo Hospitalario Universitario Insular - Materno Infantil, Las Palmas de Gran Canaria, Spain
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"apellidos" => "Rodríguez-Lago" "email" => array:1 [ 0 => "lauramatri@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Almeida-Martín" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Borrego-Hernando" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Complejo Hospitalario Universitario Insular - Materno Infantil, Las Palmas de Gran Canaria, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lesiones ampollosas de reciente aparición" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 266 "Ancho" => 900 "Tamanyo" => 94601 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Histology images. A, Acute spongiotic reaction pattern. B, Subcorneal blister containing neutrophils and periodic acid-Schiff-positive filamentous structures in the stratum corneum.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case Description</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 48-year-old woman with no past history of interest consulted for scattered pruritic skin lesions that had appeared 1 week earlier. The patient was in good general condition and had no associated systemic symptoms. Physical examination revealed nummular crusted erosive plaques of varying sizes (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and tense blisters, some with clear and others with purulent content, located generally on the upper limbs, the hypogastric region, and extensively on the lower limbs, covering the thighs and the pretibial region. Bullous lesions were more numerous on the right hand (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). No mucosal lesions were observed.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Additional Tests</span><p id="par0010" class="elsevierStylePara elsevierViewall">Purulent content from a blister was sampled for bacterial culture, and a skin biopsy of one of the lesions was performed for histology and direct immunofluorescence. Histology (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A) showed an acute spongiotic reaction pattern, with the presence of a subcorneal blister containing neutrophils and periodic acid-Schiff (PAS)-positive filamentous structures in the stratum corneum (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B). Both bacterial culture and direct immunofluorescence were negative.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">What is your diagnosis?</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Diagnosis</span><p id="par0020" class="elsevierStylePara elsevierViewall">Bullous tinea.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Clinical Course and Treatment</span><p id="par0025" class="elsevierStylePara elsevierViewall">Based on the histological findings, a complete medical history was performed, revealing previous contact with stray cats. Scales were collected for mycological culture, in which <span class="elsevierStyleItalic">Microsporum canis</span> was isolated. The lesions resolved after treatment with oral terbinafine (250<span class="elsevierStyleHsp" style=""></span>mg/d) for 4 weeks and topical imidazole.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Comment</span><p id="par0030" class="elsevierStylePara elsevierViewall">Bullous tinea, described by Costello in 1952,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> is a clinical variant of dermatophytosis, of which less than 70 cases are described in the literature. A characteristic feature is the appearance of blisters in the context of intense inflammation, usually caused by a zoophilic dermatophyte: <span class="elsevierStyleItalic">Tricophyton mentagrophytes</span> and <span class="elsevierStyleItalic">M. canis</span> are the most frequently isolated.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> The foot is the most commonly affected location. Bullous lesions are usually restricted to the edges of the plaques, and extensive lesions such as those of our patient are exceptional.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> The differential diagnosis of disseminated bullous lesions in adults is broad and includes infections, contact dermatitis, insect bites, and autoimmune blistering diseases.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> The asymmetric location of bullous lesions in tinea can help distinguish it from autoimmune blistering diseases, although differentiation is not possible in extensive cases such that described here. The secondary presentation of nonbullous tinea in the context of an autoimmune bullous disease treated with corticosteroids can also mimic bullous tinea.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> Dermatophytosis can be distinguished from bullous tinea because the former consists of a hypersensitivity reaction to a distant dermatophyte, and direct examination and culture are negative.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Bullous tinea responds to the usual treatment regimen for dermatophytosis.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> However, due to the higher rate of terbinafine resistance of <span class="elsevierStyleItalic">M. canis</span>, prolonged treatment with higher than recommended doses should be considered in these cases.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The present case illustrates an unusual manifestation of a common dermatosis that should be included in the differential diagnosis of bullous lesions in the relevant epidemiological context.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflicts of Interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case Description" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Additional Tests" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Diagnosis" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Clinical Course and Treatment" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Comment" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of Interest" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 640 "Ancho" => 650 "Tamanyo" => 38475 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erosive, crusted, nummular plaques of varying sizes, predominantly on the extremities.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 499 "Ancho" => 750 "Tamanyo" => 43663 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Tense blisters, some with clear and others with purulent content, on the hands.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 266 "Ancho" => 900 "Tamanyo" => 94601 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Histology images. A, Acute spongiotic reaction pattern. B, Subcorneal blister containing neutrophils and periodic acid-Schiff-positive filamentous structures in the stratum corneum.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Vesicular Trichophyton rubrum (purpureum) infection simulating dermatitis herpetiformis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.J. Costello" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Arch Dermatol Syphilol" "fecha" => "1952" "volumen" => "66" "paginaInicial" => "653" "paginaFinal" => "654" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0040" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Six cases of tinea bullosa in Siena, Italy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C. Romano" 1 => "E. Gaviria Morales" 2 => "L. Feci" 3 => "E. Trovato" 4 => "M. 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Sen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/ijd.IJD_483_19" "Revista" => array:6 [ "tituloSerie" => "Indian J Dermatol" "fecha" => "2020" "volumen" => "65" "paginaInicial" => "76" "paginaFinal" => "78" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32029951" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0050" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A distinct clinicopathological presentation of cutaneous dermatophytosis mimicking autoimmune blistering disorder" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.K. Padhiyar" 1 => "N.H. Patel" 2 => "T. Gajjar" 3 => "B. Patel" 4 => "A. Chhibber" 5 => "M. Buch" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Indian J Dermatol" "fecha" => "2018" "volumen" => "63" "paginaInicial" => "412" "paginaFinal" => "414" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0055" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tinea incognito in an old patient with bullous pemphigoid receiving topical high potency steroids" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Z.H. Liu" 1 => "H. Shen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.mycmed.2015.07.001" "Revista" => array:6 [ "tituloSerie" => "J Mycol Med" "fecha" => "2015" "volumen" => "25" "paginaInicial" => "245" "paginaFinal" => "246" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26278826" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0060" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bullous ulcerating tinea" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "N. Meykadeh" 1 => "K. Waltermann" 2 => "M. Shaller" 3 => "W.C. Marsch" 4 => "M. Fisher" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1468-3083.2008.03046.x" "Revista" => array:6 [ "tituloSerie" => "J Eur Acad Dermatol Venereol" "fecha" => "2009" "volumen" => "23" "paginaInicial" => "846" "paginaFinal" => "847" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19207638" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00017310/0000011300000005/v1_202206110542/S0001731022002897/v1_202206110542/en/main.assets" "Apartado" => array:4 [ "identificador" => "92865" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Casos para el diagnóstico / Cases for Diagnosis" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/00017310/0000011300000005/v1_202206110542/S0001731022002897/v1_202206110542/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731022002897?idApp=UINPBA000044" ]
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| 2023 June | 90 | 37 | 127 |
| 2023 May | 56 | 22 | 78 |
| 2023 April | 38 | 23 | 61 |
| 2023 March | 60 | 38 | 98 |
| 2023 February | 43 | 36 | 79 |
| 2023 January | 60 | 51 | 111 |
| 2022 December | 52 | 47 | 99 |
| 2022 November | 53 | 39 | 92 |
| 2022 October | 61 | 41 | 102 |
| 2022 September | 46 | 53 | 99 |
| 2022 August | 100 | 60 | 160 |
| 2022 July | 73 | 40 | 113 |
| 2022 June | 98 | 51 | 149 |
| 2022 May | 66 | 43 | 109 |
| 2022 April | 20 | 27 | 47 |
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