Case for Diagnosis
Isolated Bullae of the Scrotum in an 87 Year-Old-Man
Ampollas aisladas del escroto en un varón de 87 años
F. Alves
, A. Pinho, J.C. Cardoso
Corresponding author
Servicio de Dermatologia, Centro Hospitalario y Universitario de Coimbra, Coimbra, Portugal
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Alves, A. Pinho, J.C. Cardoso" "autores" => array:3 [ 0 => array:4 [ "nombre" => "F." "apellidos" => "Alves" "email" => array:1 [ 0 => "francisca.alves37@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Pinho" ] 2 => array:2 [ "nombre" => "J.C." "apellidos" => "Cardoso" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatologia, Centro Hospitalario y Universitario de Coimbra, Coimbra, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ampollas aisladas del escroto en un varón de 87 años" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1000 "Ancho" => 750 "Tamanyo" => 127245 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical history</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 87 year-old-man presented with a two-month history of pruritic lesions on the scrotal area. He developed a similar episode one year earlier, that lasted for a couple of weeks and improved spontaneously. There were no associated cutaneous or extracutaneous symptoms.</p><p id="par0010" class="elsevierStylePara elsevierViewall">He was chronically under enalapril and allopurinol, but denied the introduction of new systemic drugs or the application of skin products on that area.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical examination</span><p id="par0015" class="elsevierStylePara elsevierViewall">On physical examination we observed several tense bullae and vesicles located on the scrotal area, filled with clear citric fluid, grouped over erythematous patches (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Some of the lesions had already ruptured, leaving eroded and crusted areas. He had no other cutaneous or mucosal lesions. Nikolsky’s and Asboe-Hansen’s sings were negative.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathologic evaluation</span><p id="par0020" class="elsevierStylePara elsevierViewall">A punch biopsy specimen was obtained for histopathologic evaluation, revealing a subepidermal blister (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A) accompanied by a dermal inflammatory infiltrate composed of mononuclear cells and eosinophils (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Other Tests</span><p id="par0025" class="elsevierStylePara elsevierViewall">Direct immunofluorescence was temporarily unavailable, however indirect immunofluorescence and ELISA revealed IgG autoantibodies directed against bullous pemphigoid (BP) antigen 230, on a titer of 56.9 U/mL (N < 20).</p><p id="par0030" class="elsevierStylePara elsevierViewall">What is the diagnosis?</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis</span><p id="par0035" class="elsevierStylePara elsevierViewall">Genital bullous pemphigoid (GBP).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Course and Treatment</span><p id="par0040" class="elsevierStylePara elsevierViewall">The patient then began treatment with ultrapotent topical corticosteroids (0.05% clobetasol propionate ointment once a day), leading to complete resolution of skin lesions over the course of 4 weeks. No recurrence was observed during a 6-month follow-up.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Comment</span><p id="par0045" class="elsevierStylePara elsevierViewall">Bullous pemphigoid (BP) is a common autoimmune subepidermal blistering disease, presenting typically in the elderly patients as a generalized pruritic bullous eruption. This entity is an example of an immune-mediated disease that is associated with a humoral and cellular response directed against two self-antigens: BP antigen 180 and BP antigen 230<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a>. The clinical presentation can be rather polymorphic, particularly during the early stages of the disease or in atypical variants.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Localized BP is a clinical variant of bullous pemphigoid and its exact pathogenesis is yet to be elucidated, although factors such as trauma, ultraviolet light and hydrostatic pressure have been proposed<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>. Genital bullous pemphigoid (GBP) is a rarely reported localized subset<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> that affects mainly women and paediatric patients. GBP in adult men is exceptionally rare, and to our knowledge only three cases were previously reported<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The clinical differential diagnosis of GBP includes several other conditions, such as acute eczema, herpetic and fungal infections, epidermolysis bullosa and linear IgA disease. Clinical-pathological correlation is of major importance, and these entities can be differentiated on the basis of distinctive immunopathologic findings and clinical context. Early diagnosis will help avoid unnecessary and costly treatment for unrelated conditions.</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" => "Histopathologic evaluation" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Other Tests" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnosis" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical Course and Treatment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Comment" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Alves F, Pinho A, Cardoso JC. Ampollas aisladas del escroto en un varón de 87 años. Actas Dermosifiliogr. 2021;112:449–450.</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" => 1000 "Ancho" => 750 "Tamanyo" => 127245 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 622 "Ancho" => 950 "Tamanyo" => 143533 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">a) Hematoxylin-eosin 40x. b) Hematoxylin-eosin 400x.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cloning and primary structural analysis of the bullous pemphigoid autoantigen BP180" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G. 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"fecha" => "2004" "editorial" => "Saunders Ltd" "editorialLocalizacion" => "London" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Blisters on the scrotum of an infant" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E. Husein" 1 => "H. Ahmed" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1440-1754.2011.02261-1.x" "Revista" => array:6 [ "tituloSerie" => "J Paediatr Child Health" "fecha" => "2011" "volumen" => "47" "paginaInicial" => "763" "paginaFinal" => "765" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22085183" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Localized genital bullous pemphigoid" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Mounsey" 1 => "J. Heelan" 2 => "K. Hughes" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/ced.13612" "Revista" => array:6 [ "tituloSerie" => "Clin Exp Dermatol" "fecha" => "2018" "volumen" => "43" "paginaInicial" => "810" "paginaFinal" => "812" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29756688" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000011200000005/v1_202105020833/S1578219021000068/v1_202105020833/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/15782190/0000011200000005/v1_202105020833/S1578219021000068/v1_202105020833/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219021000068?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 23 | 13 | 36 |
| 2024 October | 99 | 60 | 159 |
| 2024 September | 123 | 28 | 151 |
| 2024 August | 126 | 73 | 199 |
| 2024 July | 118 | 39 | 157 |
| 2024 June | 97 | 42 | 139 |
| 2024 May | 111 | 42 | 153 |
| 2024 April | 97 | 29 | 126 |
| 2024 March | 100 | 35 | 135 |
| 2024 February | 75 | 30 | 105 |
| 2024 January | 84 | 30 | 114 |
| 2023 December | 63 | 21 | 84 |
| 2023 November | 85 | 37 | 122 |
| 2023 October | 81 | 22 | 103 |
| 2023 September | 59 | 31 | 90 |
| 2023 August | 46 | 22 | 68 |
| 2023 July | 67 | 49 | 116 |
| 2023 June | 63 | 29 | 92 |
| 2023 May | 59 | 31 | 90 |
| 2023 April | 32 | 39 | 71 |
| 2023 March | 50 | 36 | 86 |
| 2023 February | 54 | 25 | 79 |
| 2023 January | 46 | 22 | 68 |
| 2022 December | 49 | 48 | 97 |
| 2022 November | 34 | 31 | 65 |
| 2022 October | 28 | 25 | 53 |
| 2022 September | 37 | 43 | 80 |
| 2022 August | 35 | 46 | 81 |
| 2022 July | 35 | 50 | 85 |
| 2022 June | 27 | 32 | 59 |
| 2022 May | 61 | 39 | 100 |
| 2022 April | 50 | 44 | 94 |
| 2022 March | 88 | 63 | 151 |
| 2022 February | 67 | 29 | 96 |
| 2022 January | 79 | 38 | 117 |
| 2021 December | 59 | 26 | 85 |
| 2021 November | 69 | 38 | 107 |
| 2021 October | 127 | 73 | 200 |
| 2021 September | 70 | 52 | 122 |
| 2021 August | 81 | 45 | 126 |
| 2021 July | 56 | 25 | 81 |
| 2021 June | 71 | 35 | 106 |
| 2021 May | 90 | 49 | 139 |
| 2021 April | 143 | 110 | 253 |
| 2021 March | 76 | 42 | 118 |
| 2021 February | 47 | 25 | 72 |
| 2021 January | 29 | 26 | 55 |
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