Presternal Scrofuloderma: Tip of the Iceberg Unveiling Multifocal Extrapulmonary Tuberculosis - A Rare Case Report

Introduction: Scrofuloderma, a type of secondary cutaneous tuberculosis (TB) commonly arising from the underlying cervical or axillary lymph node foci via contiguity, is frequent in the pediatric population. The origin of scrofuloderma from the underlying sternal tubercular osteomyelitic focus is exceptionally unusual. It can rarely be a part of the convoluted riddle of multifocal TB, particularly in the setting of human immunodeficiency virus (HIV) infection. Case Presentation: We hereby report a 16-year-old immunocompetent female who presented with chronic, sinus-like lesions with bridging scars on the upper chest, clinically confounded with infected keloid and deep fungal infection. She was later diagnosed with scrofuloderma arising from sternal osteomyelitis compounded with multifocal tuberculosis (sternal, mediastinal, cutaneous, lumbar vertebral) and received antitubercular treatment. Conclusions: This case highlights the importance of harboring clinical scepticism supported by thorough systemic investigations while diagnosing these innocuous mimickers occurring at rare sites, even in immunocompetent individuals.

LEPROSY MASQUERADING AS DEEP FUNGAL INFECTION

Leprosy exhibits a wide spectrum of presentations, varying from the tuberculoid to the lepromatous pole, with immunologically unstable reactional states in-between, depending on the immune status of the individual. The reactional states of leprosy itself maybe the initial presentation of leprosy in some cases. We hereby report an untreated case of lepromatous leprosy in reaction mimicking deep fungal infection. Our patient is a 58 year old male, who presented with multiple episodes of painful raised lesions all over the body associated with fever and generalized malaise since 2 months. Lesions that initially developed on the trunk, later progressed to involve face and bilateral extremeties, became pustular followed by ulceration and crusting. History of signicant weight loss over the past 6 months. Cutaneous examination revealed multiple pustules, nodules over the face, ears, trunk, abdomen, both extremeties. Multiple ulcerated plaques with necrotic crusting were also present. DDs of deep fungal infection, and leprosy in erythema nodosum leprosum were considered . KOH mount for fungal elements came negative. Slit skin smear showed a bacillary index of 4+. Skin biopsy from the skin nodule revealed thinned epidermis with attened rete ridges, clear grenz zone and multiple foamy macrophages and neutrophilic inltrate in the dermis. So we conrmed it as a case of lepromatous leprosy in erythema nodosum leprosum necroticans and as the patient had no previous evidence suggestive of leprosy it was difcult to diagnose the condition clinically. Hence it is important to have a high index of clinical suspicion of leprosy and initiate prompt treatment to prevent further disabilities and reduce the morbidity associated with leprosy.

Strategies of Drug Delivery for Deep Fungal Infection: A Review

: The deep fungal infection poses serious threats to human health, mainly due to the increase in the number of immunocompromised individuals. Current first-line antifungal agents such as Amphotericin B, Fluconazole and Itraconazole, may decrease the severity of fungal infection to some extent, but the poor drug bioavailability, drug toxicity and poor water solubility seriously restrict their clinical utility. This review focuses on the study of drug delivery strategies for the treatment of deep fungal infections. We summarize the drug delivery strategies recently reported for the treatment of deep fungal infection, and explain each part with research examples. We discuss the use of pharmaceutical approaches to improve the physicochemical properties of the antifungal drugs to provide a basis for the clinical application of antifungal drugs. We then highlight the strategies for targeting drug delivery to the infection sites of fungi and fungal surface moieties, which have the potential to get developed as clinically relevant targeted therapies against deep fungal infections. It is worth noting that the current research on fungal infections still lags behind the research on other pathogens, and the drug delivery strategy for the treatment of deep fungal infections is far from meeting the treatment needs. Therefore, we envision the potential strategies inspired by the treatment of diseases with referential pathology or pathophysiology, further enriching the delivery of antifungal agents, providing references for basic research of fungal infections. Lay Summary: The deep fungal infections pose serious threats to the health of immunodeficiency patients. It is worth noting that the current research on fungi is still lagging behind that on other pathogens. The drug delivery strategies for the treatment of deep fungal infections are far from meeting the treatment needs. We summarize the recently reported drug delivery strategies for treating deep fungal infection, and envision the potential strategies to further enrich the delivery of antifungal agents.

Dysmorphic Trichophyton rubrum mimicking Blastomycosis

We will describe a 62 year old immunocompromised, diabetic, male patient who presented with several cutaneous lesions. The patient was 4 years post-nephrectomy due to renal cell carcinoma and 6 months post-renal transplantation at time of presentation. Initial clinical impression was thought to be deep fungal infection or metastatic carcinoma. Trichophyton rubrum with a dysmorphic morphology simulating blastomycosis was ultimately diagnosed.