Tsutsumi Yutaka, Odani Kentaro, Kaneko Yasuhito, Hashizume Hideo, Tachibana Mitsuhiro
Diagnostic Pathology Clinic, Pathos Tsutsumi, Nagoya, Aichi, Japan.
Department of Diagnostic Pathology, Shimada Municipal Hospital, Shimada, Shizuoka, Japan.
Case Rep Pathol. 2021 Jan 29;2021:8819560. doi: 10.1155/2021/8819560. eCollection 2021.
A mildly diabetic 58-year-old male had traumatic ulceration on the left popliteal fossa, and the lesion progressed to a painful 6 cm deep ulcer. After surgical debridement and skin grafting, ulceration recurred. Pyoderma gangrenosum was clinically diagnosed after the first biopsy, indicating a noninfective ulcer. Immunosuppressive therapy (prednisolone and cyclosporine A) induced complete epithelialization in three months. Four months later, subcutaneous nonulcerated nodules appeared on the anterior area of the left lower leg. Subcutaneous induration progressed and ulceration recurred, so that immunosuppressive therapy continued for one year. Cytomegalovirus (CMV) viremia was detected, and the second biopsy demonstrated CMV inclusions of endothelial and perivascular cells in fibrosing septolobular panniculitis. Cyclosporine A was cancelled, prednisolone was tapered, and ganciclovir started. Viremia soon disappeared, but the lesion progressed to large induration with multiple ulcers measuring up to 3 cm. The third biopsy disclosed infection of Gram-positive mycobacteria, accompanying fat droplet-centered suppurative granulomas without CMV infection. Microbial culture identified . Clarithromycin with thermotherapy was effective. A review of the second biopsy confirmed coinfection of CMV and Gram-positive mycobacteria. Immunostaining using a panel of anti-bacterial antibodies visualized the mycobacteria in the lesion. Positive findings were obtained with antibodies to Bacillus Calmette-Guérin, , MPT64 (-specific 24 kDa secretory antigen), LAM (-related lipoarabinomannan), and PAB (-specific lipoteichoic acid).
一名58岁的轻度糖尿病男性，左腘窝出现创伤性溃疡，病变进展为一个6厘米深的疼痛性溃疡。手术清创和植皮后，溃疡复发。首次活检后临床诊断为坏疽性脓皮病，提示为非感染性溃疡。免疫抑制治疗（泼尼松龙和环孢素A）在三个月内诱导完全上皮化。四个月后，左小腿前部出现皮下无溃疡结节。皮下硬结进展且溃疡复发，因此免疫抑制治疗持续了一年。检测到巨细胞病毒（CMV）病毒血症，第二次活检显示在纤维性小叶间隔性脂膜炎的内皮细胞和血管周围细胞中有CMV包涵体。停用环孢素A，逐渐减少泼尼松龙用量，并开始使用更昔洛韦。病毒血症很快消失，但病变进展为大硬结伴多个长达3厘米的溃疡。第三次活检发现革兰氏阳性分枝杆菌感染，伴有以脂肪滴为中心的化脓性肉芽肿，无CMV感染。微生物培养鉴定出……。克拉霉素联合热疗有效。对第二次活检的复查证实CMV和革兰氏阳性分枝杆菌合并感染。使用一组抗细菌抗体进行免疫染色可在病变中观察到分枝杆菌。用卡介苗、……、MPT64（-特异性24 kDa分泌抗原）、LAM（-相关脂阿拉伯甘露聚糖）和PAB（-特异性脂磷壁酸）抗体获得了阳性结果。
