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
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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. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 10 | 16 | 26 |
| 2024 Octubre | 61 | 43 | 104 |
| 2024 Septiembre | 91 | 38 | 129 |
| 2024 Agosto | 103 | 76 | 179 |
| 2024 Julio | 83 | 37 | 120 |
| 2024 Junio | 83 | 39 | 122 |
| 2024 Mayo | 70 | 40 | 110 |
| 2024 Abril | 75 | 26 | 101 |
| 2024 Marzo | 95 | 35 | 130 |
| 2024 Febrero | 63 | 39 | 102 |
| 2024 Enero | 51 | 40 | 91 |
| 2023 Diciembre | 56 | 11 | 67 |
| 2023 Noviembre | 63 | 23 | 86 |
| 2023 Octubre | 52 | 23 | 75 |
| 2023 Septiembre | 57 | 21 | 78 |
| 2023 Agosto | 33 | 17 | 50 |
| 2023 Julio | 78 | 36 | 114 |
| 2023 Junio | 64 | 21 | 85 |
| 2023 Mayo | 82 | 24 | 106 |
| 2023 Abril | 58 | 19 | 77 |
| 2023 Marzo | 75 | 22 | 97 |
| 2023 Febrero | 48 | 20 | 68 |
| 2023 Enero | 50 | 32 | 82 |
| 2022 Diciembre | 50 | 37 | 87 |
| 2022 Noviembre | 41 | 27 | 68 |
| 2022 Octubre | 17 | 24 | 41 |
| 2022 Septiembre | 25 | 38 | 63 |
| 2022 Agosto | 20 | 28 | 48 |
| 2022 Julio | 18 | 45 | 63 |
| 2022 Junio | 15 | 33 | 48 |
| 2022 Mayo | 37 | 29 | 66 |
| 2022 Abril | 37 | 44 | 81 |
| 2022 Marzo | 40 | 35 | 75 |
| 2022 Febrero | 27 | 24 | 51 |
| 2022 Enero | 33 | 38 | 71 |
| 2021 Diciembre | 21 | 40 | 61 |
| 2021 Noviembre | 37 | 45 | 82 |
| 2021 Octubre | 33 | 59 | 92 |
| 2021 Septiembre | 20 | 45 | 65 |
| 2021 Agosto | 21 | 29 | 50 |
| 2021 Julio | 36 | 37 | 73 |
| 2021 Junio | 24 | 22 | 46 |
| 2021 Mayo | 20 | 21 | 41 |
| 2021 Abril | 76 | 46 | 122 |
| 2021 Marzo | 48 | 30 | 78 |
| 2021 Febrero | 44 | 20 | 64 |
| 2021 Enero | 31 | 12 | 43 |
| 2020 Diciembre | 25 | 17 | 42 |
| 2020 Noviembre | 17 | 15 | 32 |
| 2020 Octubre | 28 | 15 | 43 |
| 2020 Septiembre | 44 | 7 | 51 |
| 2020 Agosto | 27 | 18 | 45 |
| 2020 Julio | 33 | 13 | 46 |
| 2020 Junio | 38 | 28 | 66 |
| 2020 Mayo | 22 | 21 | 43 |
| 2020 Abril | 28 | 17 | 45 |
| 2020 Marzo | 21 | 19 | 40 |
| 2020 Febrero | 4 | 7 | 11 |
| 2020 Enero | 3 | 1 | 4 |
| 2019 Diciembre | 4 | 1 | 5 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Octubre | 0 | 2 | 2 |
| 2019 Agosto | 4 | 5 | 9 |
| 2019 Julio | 4 | 4 | 8 |
| 2019 Junio | 4 | 8 | 12 |
| 2019 Mayo | 6 | 14 | 20 |
| 2019 Abril | 2 | 8 | 10 |
| 2019 Marzo | 2 | 11 | 13 |
| 2019 Febrero | 2 | 2 | 4 |
| 2019 Enero | 2 | 4 | 6 |
| 2018 Diciembre | 3 | 0 | 3 |
| 2018 Octubre | 2 | 0 | 2 |
| 2018 Septiembre | 3 | 0 | 3 |
| 2018 Mayo | 0 | 7 | 7 |
| 2018 Abril | 0 | 4 | 4 |
| 2018 Marzo | 0 | 1 | 1 |
| 2018 Febrero | 33 | 3 | 36 |
| 2018 Enero | 41 | 6 | 47 |
| 2017 Diciembre | 31 | 8 | 39 |
| 2017 Noviembre | 32 | 6 | 38 |
| 2017 Octubre | 33 | 4 | 37 |
| 2017 Septiembre | 37 | 4 | 41 |
| 2017 Agosto | 68 | 16 | 84 |
| 2017 Julio | 35 | 11 | 46 |
| 2017 Junio | 56 | 15 | 71 |
| 2017 Mayo | 52 | 4 | 56 |
| 2017 Abril | 36 | 10 | 46 |
| 2017 Marzo | 29 | 30 | 59 |
| 2017 Febrero | 35 | 11 | 46 |
| 2017 Enero | 22 | 8 | 30 |
| 2016 Diciembre | 45 | 5 | 50 |
| 2016 Noviembre | 47 | 12 | 59 |
| 2016 Octubre | 50 | 13 | 63 |
| 2016 Septiembre | 41 | 8 | 49 |
| 2016 Agosto | 44 | 18 | 62 |
| 2016 Julio | 44 | 13 | 57 |
| 2016 Junio | 7 | 15 | 22 |
| 2016 Mayo | 11 | 17 | 28 |
| 2016 Abril | 3 | 5 | 8 |
| 2016 Marzo | 6 | 7 | 13 |
| 2016 Febrero | 6 | 6 | 12 |
| 2016 Enero | 4 | 2 | 6 |
| 2015 Diciembre | 7 | 0 | 7 |
| 2015 Noviembre | 17 | 4 | 21 |
| 2015 Octubre | 16 | 3 | 19 |
| 2015 Septiembre | 6 | 4 | 10 |
| 2015 Agosto | 11 | 5 | 16 |
| 2015 Julio | 58 | 6 | 64 |
| 2015 Junio | 39 | 4 | 43 |
| 2015 Mayo | 55 | 5 | 60 |
| 2015 Abril | 39 | 12 | 51 |
| 2015 Marzo | 46 | 9 | 55 |
| 2015 Febrero | 39 | 6 | 45 |
| 2015 Enero | 29 | 14 | 43 |
| 2014 Diciembre | 31 | 7 | 38 |
| 2014 Noviembre | 52 | 11 | 63 |
| 2014 Octubre | 54 | 20 | 74 |
| 2014 Septiembre | 13 | 0 | 13 |
| 2014 Agosto | 18 | 4 | 22 |
| 2014 Julio | 18 | 2 | 20 |
| 2014 Junio | 30 | 2 | 32 |
| 2014 Mayo | 38 | 9 | 47 |
| 2014 Abril | 42 | 1 | 43 |
| 2014 Marzo | 37 | 6 | 43 |
| 2014 Febrero | 34 | 7 | 41 |
| 2014 Enero | 21 | 2 | 23 |
| 2013 Diciembre | 26 | 5 | 31 |
| 2013 Noviembre | 25 | 4 | 29 |
| 2013 Octubre | 17 | 3 | 20 |
| 2013 Septiembre | 18 | 2 | 20 |
| 2013 Agosto | 11 | 7 | 18 |
| 2013 Julio | 13 | 7 | 20 |
| 2013 Junio | 7 | 8 | 15 |
| 2013 Mayo | 12 | 6 | 18 |
| 2013 Abril | 14 | 10 | 24 |
| 2013 Marzo | 19 | 5 | 24 |
| 2013 Febrero | 28 | 6 | 34 |
| 2013 Enero | 42 | 1 | 43 |
| 2012 Diciembre | 32 | 6 | 38 |
| 2012 Noviembre | 1 | 0 | 1 |
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