Cases for Diagnosis
Malar Nodule in an Immunosuppressed Man
Nódulo malar en un varón inmunodeprimido
A. Pulido Pérez
, M.C. Fernández-Antón Martínez, R. Suárez Fernández
Corresponding author
Servicio de Dermatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Pulido Pérez, M.C. Fernández-Antón Martínez, R. Suárez Fernández" "autores" => array:3 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Pulido Pérez" "email" => array:1 [ 0 => "ana.pulido@madrimasd.net" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M.C." "apellidos" => "Fernández-Antón Martínez" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Suárez Fernández" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Dermatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nódulo malar en un varón inmunodeprimido" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 668 "Ancho" => 900 "Tamanyo" => 246606 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×100.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 72-year-old man was assessed for the sudden onset of an asymptomatic lesion in the malar region associated with a slight worsening of dyspnea but no sputum or fever. The patient had a history of chronic obstructive pulmonary disease for which he had been receiving treatment for several years with inhaled fluticasone propionate and repeated cycles of oral methylprednisolone.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed a nodule of elastic consistency that was nonfluctuant but not attached to the underlying tissue (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The surface skin was intact, and no other lesions were present in the mouth or at other sites.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Additional Tests</span><p id="par0015" class="elsevierStylePara elsevierViewall">A punch biopsy revealed a whitish-yellow granular material, which was sterile in standard culture media. Histopathology showed an inflammatory infiltrate in the reticular dermis composed of lymphocytes, histiocytes, and numerous polymorphonuclear cells in addition to diffuse structures with basophilic cores surrounded by a filamentous eosinophilic halo (Gram, silver methenamine, and periodic acid-Schiff positive) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Computed tomography of the head, neck, and abdomen revealed multiple minute, cavitated nodules distributed throughout both lung fields. Blood and sputum cultures were sterile.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What Is Your Diagnosis?</span></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnosis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Disseminated actinomycosis.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Clinical Course</span><p id="par0030" class="elsevierStylePara elsevierViewall">The clinical, histopathologic, and radiologic findings led to a presumptive diagnosis of disseminated actinomycosis in a patient who had undergone prolonged treatment with steroids. During his hospital stay, the patient received intravenous ceftriaxone and after discharge he continued treatment with oral amoxicillin plus clavulanic acid. Radiologic assessment 3 months after completion of antibiotic treatment showed a considerable reduction in lung involvement, with no evidence of recurrence or new subcutaneous nodular lesions.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Actinomycosis is a chronic suppurative disease caused by gram-positive, non-acid-fast bacteria of the <span class="elsevierStyleItalic">Actinomyces</span> genus.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> These colonizing microorganisms are normally found in the gastrointestinal tract (from the oropharynx to the distal intestine) and the female genital apparatus, but they are considered to be opportunistic pathogens in specific situations, such as immunosuppression, diabetes mellitus, impaired mucosal barrier, and bronchial aspiration. The most common clinical forms are cervicofacial, lung, and abdominal.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Skin involvement can be the result of contiguous spread resulting from maxillofacial injury or dental work, or may be caused by dissemination through the blood stream from a primary infection in one of the sites mentioned above. Clinically the lesions are asymptomatic, slow-growing abscesses or nodules with a tendency to fistulize. They exude a yellowish-white granular material (also known as sulfur granules), which contains filamentous bacterial colonies, associated with tissue elements in the exudate.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Microbiological diagnosis is usually difficult for a variety of reasons, including the presence of other microorganisms in the samples and prior antibiotic treatment However, one of the main causes of the failure to diagnose this condition, particularly in extra-mandibular sites, is the failure to obtain and transport the sample under anaerobic conditions as a result of a low level of clinical suspicion.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6</span></a> Blood and sputum cultures are usually negative in the pulmonary and disseminated forms. When microbiological isolation fails, treatment with beta-lactam antibiotics should be administered to patients who present symptoms suggestive of infection with bacteria of the genus <span class="elsevierStyleItalic">Actinomyces</span> in the presence of histopathologic findings compatible with this diagnosis.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The differential diagnosis should include adnexal tumors, infundibular cysts, skin metastases, and other disorders caused by agents that produce actinomycetoma, such as <span class="elsevierStyleItalic">Nocardia</span> and <span class="elsevierStyleItalic">Streptomyces somaliensis</span> species.</p><p id="par0045" class="elsevierStylePara elsevierViewall">While various antibiotics are effective against <span class="elsevierStyleItalic">Actinomyces</span>, beta-lactam antibiotics (penicillin, ampicillin, amoxicillin, cephalosporins) are the first-line option. Clindamycin, doxycycline, and macrolides can be used for patients allergic to beta-lactams. Surgical drainage should be performed if the lesions are accessible.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of Interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Additional Tests" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Clinical Course" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of Interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Pulido Pérez A, Fernández-Antón Martínez MC, Suárez Fernández R. Nódulo malar en un varón inmunodeprimido. Actas Dermosifiliogr.2012;103:735-736.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1213 "Ancho" => 900 "Tamanyo" => 210961 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Nonulcerated malar nodule.</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" => 668 "Ancho" => 900 "Tamanyo" => 246606 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×100.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Actinomycosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "V.K. 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Brook" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1586/eri.11.142" "Revista" => array:6 [ "tituloSerie" => "Expert Rev Anti Infect Ther" "fecha" => "2011" "volumen" => "9" "paginaInicial" => "1097" "paginaFinal" => "1099" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22114958" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Actinomycosis: diagnosis and management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "I. Brook" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/SMJ.0b013e3181864c1f" "Revista" => array:6 [ "tituloSerie" => "South Med J" "fecha" => "2008" "volumen" => "101" "paginaInicial" => "1019" "paginaFinal" => "1023" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18791528" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010300000008/v1_201304241323/S1578219012002557/v1_201304241323/en/main.assets" "Apartado" => array:4 [ "identificador" => "6154" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case for Diagnosis" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010300000008/v1_201304241323/S1578219012002557/v1_201304241323/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219012002557?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 16 | 27 |
| 2024 October | 61 | 43 | 104 |
| 2024 September | 91 | 38 | 129 |
| 2024 August | 103 | 76 | 179 |
| 2024 July | 83 | 37 | 120 |
| 2024 June | 83 | 39 | 122 |
| 2024 May | 70 | 40 | 110 |
| 2024 April | 75 | 26 | 101 |
| 2024 March | 95 | 35 | 130 |
| 2024 February | 63 | 39 | 102 |
| 2024 January | 51 | 40 | 91 |
| 2023 December | 56 | 11 | 67 |
| 2023 November | 63 | 23 | 86 |
| 2023 October | 52 | 23 | 75 |
| 2023 September | 57 | 21 | 78 |
| 2023 August | 33 | 17 | 50 |
| 2023 July | 78 | 36 | 114 |
| 2023 June | 64 | 21 | 85 |
| 2023 May | 82 | 24 | 106 |
| 2023 April | 58 | 19 | 77 |
| 2023 March | 75 | 22 | 97 |
| 2023 February | 48 | 20 | 68 |
| 2023 January | 50 | 32 | 82 |
| 2022 December | 50 | 37 | 87 |
| 2022 November | 41 | 27 | 68 |
| 2022 October | 17 | 24 | 41 |
| 2022 September | 25 | 38 | 63 |
| 2022 August | 20 | 28 | 48 |
| 2022 July | 18 | 45 | 63 |
| 2022 June | 15 | 33 | 48 |
| 2022 May | 37 | 29 | 66 |
| 2022 April | 37 | 44 | 81 |
| 2022 March | 40 | 35 | 75 |
| 2022 February | 27 | 24 | 51 |
| 2022 January | 33 | 38 | 71 |
| 2021 December | 21 | 40 | 61 |
| 2021 November | 37 | 45 | 82 |
| 2021 October | 33 | 59 | 92 |
| 2021 September | 20 | 45 | 65 |
| 2021 August | 21 | 29 | 50 |
| 2021 July | 36 | 37 | 73 |
| 2021 June | 24 | 22 | 46 |
| 2021 May | 20 | 21 | 41 |
| 2021 April | 76 | 46 | 122 |
| 2021 March | 48 | 30 | 78 |
| 2021 February | 44 | 20 | 64 |
| 2021 January | 31 | 12 | 43 |
| 2020 December | 25 | 17 | 42 |
| 2020 November | 17 | 15 | 32 |
| 2020 October | 28 | 15 | 43 |
| 2020 September | 44 | 7 | 51 |
| 2020 August | 27 | 18 | 45 |
| 2020 July | 33 | 13 | 46 |
| 2020 June | 38 | 28 | 66 |
| 2020 May | 22 | 21 | 43 |
| 2020 April | 28 | 17 | 45 |
| 2020 March | 21 | 19 | 40 |
| 2020 February | 4 | 7 | 11 |
| 2020 January | 3 | 1 | 4 |
| 2019 December | 4 | 1 | 5 |
| 2019 November | 4 | 0 | 4 |
| 2019 October | 0 | 2 | 2 |
| 2019 August | 4 | 5 | 9 |
| 2019 July | 4 | 4 | 8 |
| 2019 June | 4 | 8 | 12 |
| 2019 May | 6 | 14 | 20 |
| 2019 April | 2 | 8 | 10 |
| 2019 March | 2 | 11 | 13 |
| 2019 February | 2 | 2 | 4 |
| 2019 January | 2 | 4 | 6 |
| 2018 December | 3 | 0 | 3 |
| 2018 October | 2 | 0 | 2 |
| 2018 September | 3 | 0 | 3 |
| 2018 May | 0 | 7 | 7 |
| 2018 April | 0 | 4 | 4 |
| 2018 March | 0 | 1 | 1 |
| 2018 February | 33 | 3 | 36 |
| 2018 January | 41 | 6 | 47 |
| 2017 December | 31 | 8 | 39 |
| 2017 November | 32 | 6 | 38 |
| 2017 October | 33 | 4 | 37 |
| 2017 September | 37 | 4 | 41 |
| 2017 August | 68 | 16 | 84 |
| 2017 July | 35 | 11 | 46 |
| 2017 June | 56 | 15 | 71 |
| 2017 May | 52 | 4 | 56 |
| 2017 April | 36 | 10 | 46 |
| 2017 March | 29 | 30 | 59 |
| 2017 February | 35 | 11 | 46 |
| 2017 January | 22 | 8 | 30 |
| 2016 December | 45 | 5 | 50 |
| 2016 November | 47 | 12 | 59 |
| 2016 October | 50 | 13 | 63 |
| 2016 September | 41 | 8 | 49 |
| 2016 August | 44 | 18 | 62 |
| 2016 July | 44 | 13 | 57 |
| 2016 June | 7 | 15 | 22 |
| 2016 May | 11 | 17 | 28 |
| 2016 April | 3 | 5 | 8 |
| 2016 March | 6 | 7 | 13 |
| 2016 February | 6 | 6 | 12 |
| 2016 January | 4 | 2 | 6 |
| 2015 December | 7 | 0 | 7 |
| 2015 November | 17 | 4 | 21 |
| 2015 October | 16 | 3 | 19 |
| 2015 September | 6 | 4 | 10 |
| 2015 August | 11 | 5 | 16 |
| 2015 July | 58 | 6 | 64 |
| 2015 June | 39 | 4 | 43 |
| 2015 May | 55 | 5 | 60 |
| 2015 April | 39 | 12 | 51 |
| 2015 March | 46 | 9 | 55 |
| 2015 February | 39 | 6 | 45 |
| 2015 January | 29 | 14 | 43 |
| 2014 December | 31 | 7 | 38 |
| 2014 November | 52 | 11 | 63 |
| 2014 October | 54 | 20 | 74 |
| 2014 September | 13 | 0 | 13 |
| 2014 August | 18 | 4 | 22 |
| 2014 July | 18 | 2 | 20 |
| 2014 June | 30 | 2 | 32 |
| 2014 May | 38 | 9 | 47 |
| 2014 April | 42 | 1 | 43 |
| 2014 March | 37 | 6 | 43 |
| 2014 February | 34 | 7 | 41 |
| 2014 January | 21 | 2 | 23 |
| 2013 December | 26 | 5 | 31 |
| 2013 November | 25 | 4 | 29 |
| 2013 October | 17 | 3 | 20 |
| 2013 September | 18 | 2 | 20 |
| 2013 August | 11 | 7 | 18 |
| 2013 July | 13 | 7 | 20 |
| 2013 June | 7 | 8 | 15 |
| 2013 May | 12 | 6 | 18 |
| 2013 April | 14 | 10 | 24 |
| 2013 March | 19 | 5 | 24 |
| 2013 February | 28 | 6 | 34 |
| 2013 January | 42 | 1 | 43 |
| 2012 December | 32 | 6 | 38 |
| 2012 November | 1 | 0 | 1 |
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