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\begin{document}

\title{Blastomycosis-like pyoderma in an immunocompetent patient}



\author[1]{Fatma Sahli}%
\author[2]{Noureddine Litaiem}%
\author[2]{Soumaya Gara}%
\author[2]{Olfa Charfi}%
\author[2]{soumaya Rammeh}%
\author[2]{Faten Zeglaoui}%
\affil[1]{Hôpital Charles Nicolle}%
\affil[2]{Charles Nicolle Hospital}%


\vspace{-1em}



  
  \date{May 28, 2024}


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\begin{abstract}
Bastomycosis-like pyoderma is a rare skin disorder most commonly caused
by bacterial infection. It is usually diagnosed in immunocompromised
patients. We report a case of BLP in an immunocompetent woman, who
presented with a 6-week history of verrucous cutaneous plaque of the
left wrist.%
\end{abstract}%



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\emph{Title}\textbf{: Blastomycosis-like pyoderma in an immunocompetent
patient}

Authors: Sahli F, Litaiem N, Gara S, Charfi O, Rammeh S, Zeglaoui F

\emph{Author names and affiliations:}

Fatma SAHLI\textsuperscript{1,2}, MD, Noureddine
LITAIEM\textsuperscript{1,2}, Soumaya GARA\textsuperscript{1,2}~,MD,
Olfa CHARFI\textsuperscript{1,2}~,MD, Soumaya
RAMMEH\textsuperscript{2,3}, MD, Faten ZEGLAOUI\textsuperscript{1,2},
MD,

\begin{enumerate}
\tightlist
\item
  Department of Dermatology, Charles Nicolle Hospital, Tunis, Tunisia
\item
  Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis,
  Tunisia
\item
  Department of Pathology, Charles Nicolle Hospital, Tunis, Tunisia
\end{enumerate}

\emph{Corresponding author:}

Fatma Sahli

Department of dermatology, Charles Nicolle Hospital, Tunis, Tunisia

Email address~: sahlifatma@hotmail.com

\emph{Conflict of Interest Disclosure:} None Declared

\emph{Funding Sources:} None.

\textbf{Keywords:} dermatology, health maintenance, infectious diseases

\textbf{Key Clinical Message:} BLP is a rare and uncommon inflammatory
disease of the skin.

The diagnosis is sometimes confusing and the clinic may suggest a
pyoderma gangrenosum, mycobacterial infections or cutaneous
tuberculosis.

\textbf{INTRODUCTION}

Blastomycosis-like pyoderma (BLP) is a rare cutaneous disorder. It
presents as large verrucous plaques with multiple pustules and an
elevated border {[}11\emph{References~:}Hongal AA, Gejje S.
Blastomycosis-Like Pyoderma- A Rare Case Report. J Clin Diagn Res. 2016
Oct; 10(10): WD03--WD04.{]}. It is considered to be an exaggerated
inflammatory response to bacteria, especially\emph{Staphylococcus
aureus} .

BLP often occurs in patients with impaired immunological capacity
{[}22Guidry JA, Downing C, Tyring SK. Deep Fungal Infections,
Blastomycosis-Like Pyoderma, and Granulomatous Sexually Transmitted
Infections. Dermatol Clin. 2015;33(3):595-607.{]}. We describe a rare
case of BLP in an immunocompetent female patient.

\textbf{CASE REPORT}

A 65-year-old woman with diabetes mellitus type 2 presented with a
6-week history of verrucous cutaneous plaque of the anterior aspect of
the left wrist. The lesion was painful and ulcerated. The patient denied
any history of trauma or contact with patients with tuberculosis.
Dermatological examination revealed an irregular, erythematous, and
vegetating plaque of the right wrist, measuring 10 x 4 cm, with elevated
and erythematous borders with multiple pustules of different sizes and
central ulceration (\textbf{figure 1} ). There was no palpable
lymphadenopathy and physical examination was otherwise unremarkable.

Bacterial culture from a pus swab identified \emph{Staphylococcus
aureus} . Histopathological examination of a skin biopsy specimen showed
acanthosis of the epidermis with inflammatory infiltration of the dermis
made of lymphocytes, neutrophils, plasma cells, and histiocytes. The
search of Leishmania by direct microscopy and polymerase chain reaction
was negative.

The diagnosis of BLP was made. The patient received amoxicillin (3gr
daily) with clavulanic acid (62.5 mg daily) and local wound care for 20
days. Substantial improvement was seen after 6 days (\textbf{figure 2}
). A total resolution was obtained and no recurrence was noted after 6
months (\textbf{figure 3} ).

\textbf{DISCUSSION}

BLP is an exaggerated chronic inflammatory reaction due to a bacterial
infection {[}1{]}. It presents as vegetating skin lesions similar to
blastomycosis or warty tuberculosis {[}2{]}. BLP is usually diagnosed in
immunocompromised patients {[}2{]}. In these cases, BLP is related to
several factors: HIV infection, alcoholism, neoplasia, malnutrition, and
immunosuppressant drugs {[}2{]}. Cases of BLP in immunocompetent
patients are rare. Local factors may be involved including injury,
foreign bodies, tattoos, radiotherapy, and trauma {[}11Cecchi R, Bartoli
L, Brunetti L, and Pavesi M. Blastomycosis-like pyoderma in association
with recurrent vesicular hand eczema: good response to acitretin.
\emph{Dermatol Online J} . 2011 Mar; 17(3):9.\emph{Figure
legend:}\textbf{Figure 1:} Vegetating plaque of the right wrist with
elevated borders, multiple pustules and central
ulceration.\textbf{Figure 2:} Substantial improvement after 6-day
antibiotic treatment\textbf{Figure 3:} A resolution was noted after 6
months leaving a dyspigmented scar{]}.

Numerous micro-organisms are associated with BLP
including\emph{Staphylococcus, Streptococcus pyogenes, Pseudomonas
aeruginosa, Escherichia coli, and Candida albicans} . However,
\emph{Staphylococcus aureus} is the most common causative
micro-organism. The mechanism by which these microorganisms induce PLP
remains unknown. Many believe that the microbiological agent is not
directly responsible for the disease but by creating an immune
dysfunction {[}3{]}.

Su et al introduced {[}2{]} diagnostic criteria for BLP: (i) large
verrucous plaques with multiple pustules and elevated border, (ii)
histological evidence of pseudoepitheliomatous hyperplasia with
abscesses, (iii) identifications of bacteria by tissue culture,
(iv)negative culture for fungi and mycobacteria, (v) negative fungal
serology tests and (vi) normal bromide and iodide blood levels. Our
patient met four of these criteria.

The most effective treatment strategy includes targeted oral antibiotic
therapy. Other treatment options could be considered for selected
patients and include curettage, topical antibiotics, oral acitretin,
intralesional or systemic corticosteroids, and carbon dioxide laser
debridement {[}3{]}.

\emph{Author contribution statement:} Noureddine Litaiem wrote the first
draft of the manuscript. Soumaya Gara, Olfa Charfi and Soumaya Rammeh
managed the literature searches and analyses. Mariem Jones and Faten
Zeglaoui revised the manuscript. All the authors contributed to and have
approved the final manuscript.\selectlanguage{english}
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