Diagnosis at first sight
Skin nodules in a pediatric Mexican patient after chest trauma
Nódulos cutáneos en un paciente pediátrico mexicano posterior a traumatismo en tórax
Ana María Medina-Torresa, Sonia Toussaint-Caireb, Rigoberto Hernández-Castroc, Alexandro Bonifazd,
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a Departamento de Dermatología, Hospital Infantil de México Federico Gómez, Mexico City, CDMX, Mexico
b Servicio de Dermatopatología, Hospital General Dr. Manuel Gea González, Mexico City, CDMX, Mexico
c Departamento de Ecología de Agentes Patógenos, Hospital General Dr. Manuel Gea González, Mexico City, CDMX, Mexico
d Servicio de Dermatología, Departamento de Micología, Hospital General de México Dr. Eduardo Liceaga, Mexico City, CDMX, Mexico
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"a_bonifaz@yahoo.com.mx" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Departamento de Dermatología, Hospital Infantil de México Federico Gómez, Mexico City, CDMX, Mexico" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatopatología, Hospital General Dr. Manuel Gea González, Mexico City, CDMX, Mexico" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Ecología de Agentes Patógenos, Hospital General Dr. Manuel Gea González, Mexico City, CDMX, Mexico" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Dermatología, Departamento de Micología, Hospital General de México Dr. Eduardo Liceaga, Mexico City, CDMX, Mexico" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nódulos cutáneos en un paciente pediátrico mexicano posterior a traumatismo en tórax" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1125 "Ancho" => 1500 "Tamanyo" => 525099 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histopathology: suppurative granuloma, with the presence of basophilic kidney-shaped granules and spikes in periphery (H&E, 10, 20 and ×40).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">The case discusses a 12-year-old male who was treated at the Dermatology Department of the Hospital Infantil de México Federico Gómez, originally from Iguala Guerrero (south-eastern Mexico). He presented with disseminated dermatosis, which had started six months previously, of the anterior chest and right axillary regions, and on the ventral surface of the ipsilateral right arm, made up of five nodules measuring 2<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>cm, slightly erythematosus, firm, not painful, non-fistulising and without exudate (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). He reported that the dermatosis started one month after falling from a motorbike, in which initially he only presented with minor bruising.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Clinical diagnosis and course</span><p id="par0010" class="elsevierStylePara elsevierViewall">Given the suspicion of deep mycosis, a biopsy was performed. In the reticular dermis and subcutaneous cellular tissue a diffuse dense inflammatory infiltrate was observed, composed of neutrophilic microabscesses, histiocytes and multinucleated giant cells, with formation of granulomas and kidney-shaped granules (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). In the mycological study, multiple small, kidney-shaped granules were observed in the direct examination (KOH 10%) with spikes in the periphery, corresponding to the <span class="elsevierStyleItalic">Nocardia</span> type (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Limited, white, rocky colonies developed in the culture in Sabouraud dextrose agar media. These were identified by biochemical tests and by amplification and sequencing of the gene 16S rRNA. It was based on the sequencing of the gene 16S rRNA, using the primers: Noc1 (5′-GCTTAACACATGCAAGTCG-3′) and Noc2 (5′-GAATTCCAGTCTCCCCTG-3′). The polymerase chain reaction (PCR) product was purified and analysed in a DNA sequencing of Applied Biosystems® 3730 system (Foster City, CA, USA). The 16S sequence showed a 100% homology with <span class="elsevierStyleItalic">Nocardia brasiliensis</span>.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> The access number to the GenBank sequence was: MK603972. Based on the above, the diagnosis of actinomycetoma caused by <span class="elsevierStyleItalic">N. brasiliensis</span> was confirmed.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The chest and right arm X-rays ruled out bone involvement. The white blood cell and reticulocyte count, liver enzymes and glucose-6-phosphate dehydrogenase levels were normal. Treatment was therefore started with trimethoprim/sulfamethoxazole 160/800<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h and diaminodiphenyl sulfone 50<span class="elsevierStyleHsp" style=""></span>mg/day. The patient presented improvement from the second month of treatment, with no evidence of adverse effects, and completed six months of treatment, obtaining clinical and microbiological cure.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Final comments</span><p id="par0020" class="elsevierStylePara elsevierViewall">Mycetoma is a subcutaneous chronic and localised infection due to implantation. It is divided into two: eumycetoma caused by filamentous fungi and actinomycetoma caused by aerobic filamentous actinomycetes<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a>; the first type is most common in Africa and India and the second is most common in America, mainly in Mexico and Venezuela.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2–5</span></a> The countries with the greatest prevalence are in the area called the ‘mycetoma belt’ latitude 15° south and 30° north of the Tropic of Cancer), subtropical and tropical dry climate regions.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3,5</span></a> Mexico is the country with the highest number of reports in America, in particular cases of actinomycetoma caused by <span class="elsevierStyleItalic">Nocardia brasiliensis</span> in up to 80% of cases<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,5</span></a>; it affects more males between 21 and 30 years of age, and is considered an occupational disease, with the most affected individuals being those who work in the countryside with minimal protection.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3,5</span></a> Actinomycetoma in children is a rare entity. It is observed more in endemic areas and its explanation is that they also work in the countryside with little protection or due to living in rural areas in which they are more exposed to traumas which are a means of entry for fungi and actinomycetes.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3,6–8</span></a> In an extensive Mexican report (3993 cases), mycetomas under the age of 15 represent 3.94%, with predominance in males and due to <span class="elsevierStyleItalic">N. brasiliensis</span>.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">There are three factors for its development: appropriate inoculum, immunological status and hormonal adaptation.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,8</span></a> The absence of sex hormones in pediatric patients is probably related to the lower frequency.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,8,9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The clinical manifestations in children and adults are similar; they are common in lower limbs (70%) and rare on the trunk. In children, they are specifically reported in 0.1%.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6–9</span></a> The clinical manifestation is of lesions with increased volume, deformation, nodules and fistulas through which a stringy exudate containing parasitic forms called “granules” drains. In children and adolescents, a limited clinical form of nodular lesions has been reported which rarely develop into a fistula and which are called “mini-mycetoma”. These clinical symptoms are very similar to the nodules of our patient. Mild pain and a little itchiness may be presented.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,6,8,9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The diagnosis is confirmed with the observation of the “granules” either in the direct examination or through the histopathology. The latter is made up of chronic suppurative granulomas and polymorphonuclear microabscesses. Cultures are fundamental to determine the aetiology and <span class="elsevierStyleItalic">in vitro</span> susceptibility tests can be performed. Molecular identification of actinomycetes such as <span class="elsevierStyleItalic">Nocardia</span> is often done using PCR techniques (16S rRNA gene), which is the technique with the greatest specificity and is considered as the gold standard.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3,6,8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Treatment depends on the causative agent and on the patient's condition. In the case of actinomycetoma caused by <span class="elsevierStyleItalic">Nocardia</span>, the combination of trimethoprim–sulfamethoxazole and diaminodiphenyl sulfone has been used both in children and in adults. These achieve recovery in most cases and are well tolerated despite being indicated for a prolonged period of time (6–8 months).<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8–10</span></a> In the event of therapeutic failure, the use of amoxicillin/clavulanic acid, amikacin and imipenem may be considered.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,8</span></a></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical diagnosis and course" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Final comments" ] 3 => 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: Medina-Torres AM, Toussaint-Caire S, Hernández-Castro R, Bonifaz A. Nódulos cutáneos en un paciente pediátrico mexicano posterior a traumatismo en tórax. Enferm Infecc Microbiol Clin. 2019;37:611–613.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1125 "Ancho" => 1500 "Tamanyo" => 166753 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Nodular lesions in pectoral region. A nodular, crusty lesion can be observed on the arm.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1125 "Ancho" => 1500 "Tamanyo" => 525099 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histopathology: suppurative granuloma, with the presence of basophilic kidney-shaped granules and spikes in periphery (H&E, 10, 20 and ×40).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 938 "Ancho" => 1250 "Tamanyo" => 349325 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Granules in the direct examination (Lugol, ×40). 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 2 | 4 |
| 2024 October | 21 | 10 | 31 |
| 2024 September | 35 | 11 | 46 |
| 2024 August | 29 | 11 | 40 |
| 2024 July | 25 | 4 | 29 |
| 2024 June | 33 | 5 | 38 |
| 2024 May | 38 | 2 | 40 |
| 2024 April | 51 | 4 | 55 |
| 2024 March | 84 | 7 | 91 |
| 2024 February | 42 | 7 | 49 |
| 2024 January | 46 | 5 | 51 |
| 2023 December | 47 | 8 | 55 |
| 2023 November | 46 | 4 | 50 |
| 2023 October | 38 | 1 | 39 |
| 2023 September | 8 | 1 | 9 |
| 2023 August | 12 | 2 | 14 |
| 2023 July | 8 | 6 | 14 |
| 2023 June | 20 | 3 | 23 |
| 2023 May | 29 | 3 | 32 |
| 2023 April | 17 | 2 | 19 |
| 2023 March | 17 | 2 | 19 |
| 2023 February | 21 | 12 | 33 |
| 2023 January | 52 | 2 | 54 |
| 2022 December | 30 | 7 | 37 |
| 2022 November | 33 | 9 | 42 |
| 2022 October | 24 | 9 | 33 |
| 2022 September | 18 | 7 | 25 |
| 2022 August | 18 | 9 | 27 |
| 2022 July | 7 | 5 | 12 |
| 2022 June | 11 | 9 | 20 |
| 2022 May | 17 | 8 | 25 |
| 2022 April | 31 | 8 | 39 |
| 2022 March | 30 | 7 | 37 |
| 2022 February | 29 | 7 | 36 |
| 2022 January | 57 | 6 | 63 |
| 2021 December | 35 | 7 | 42 |
| 2021 November | 25 | 8 | 33 |
| 2021 October | 29 | 12 | 41 |
| 2021 September | 18 | 7 | 25 |
| 2021 August | 29 | 6 | 35 |
| 2021 July | 19 | 6 | 25 |
| 2021 June | 25 | 8 | 33 |
| 2021 May | 25 | 13 | 38 |
| 2021 April | 58 | 14 | 72 |
| 2021 March | 23 | 7 | 30 |
| 2021 February | 10 | 10 | 20 |
| 2021 January | 14 | 11 | 25 |
| 2020 December | 13 | 3 | 16 |
| 2020 November | 10 | 5 | 15 |
| 2020 October | 6 | 2 | 8 |
| 2020 September | 13 | 7 | 20 |
| 2020 August | 21 | 10 | 31 |
| 2020 July | 10 | 15 | 25 |
| 2020 June | 9 | 2 | 11 |
| 2020 May | 8 | 8 | 16 |
| 2019 November | 1 | 2 | 3 |
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