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[Cutaneous malacoplakia: a pediatric case]
O Enjolras1, J Guillemette, A Carlotti
1Service de Dermatologie, Hôpital Tarnier-Cochin, Paris.
Introduction:
Cutaneous malakoplakia is an inflammatory disease characterized by granulomatous accumulation of distinctive phagocytic macrophages. It occurs mainly in visceral or orificial areas; the condition is rarely purely cutaneous, and appears to be extremely rare in childhood.
Case Report:
A facial cutaneous crusted lesion was diagnosed as cutaneous malakoplakia in an immunocompetent child. The lesion had been excised twice and it had recurred, and the diagnosis was made possible only with a third biopsy, after a 2-year chronic expansion. This third biopsy revealed a dense granulomatous inflammation with numerous phagocytic histiocytes containing abundant fine granules and round Michaelis-Gutmann bodies, both staining with PAS, Perls and von Kossa. Biopsy cultures revealed only growth of two different streptococcus (group B) strains. The lesion resolved after a 4-month period of antibiotic therapy, including roxithromycin, ampicillin and trimethoprim-sulfamethoxasole.
Discussion:
Diagnosis of malakoplakia is mainly made by histopathologic examination of tissue excision or biopsies. There are no specific clinical features. Most reported cases of this uncommon phagocytic reaction to common bacteria have developed in the genitourinary areas (71 p. 100); purely cutaneous localisation, as in our patient, are rare (4 p. 100). Intracytoplasmic granules may result from phagolysosomes and incomplete bacterial killing, with subsequent deposit of iron and calcium in the phagocytic macrophages. A number of reported cases have affected immunocompromised patients with either congenital immunodeficiency or secondary immunodeficiency. The most effective treatment option is based on a protracted antibiotherapy, using drugs that easily permeate the macrophages, e.g. quinolones and trimethoprim-sulfamethoxasole. Lesion may recur after surgical excision.
Insights
Cutaneous malakoplakia, a rare inflammatory condition, was diagnosed in an immunocompetent child. Prompt antibiotic therapy led to lesion resolution, highlighting effective treatment for this rare presentation.
Area of Science:
- Dermatology
- Pediatric Pathology
- Infectious Diseases
Background:
- Cutaneous malakoplakia is a rare inflammatory condition typically affecting visceral or orificial areas, seldom presenting purely on the skin.
- It is characterized by granulomatous inflammation and the accumulation of distinctive phagocytic macrophages.
Observation:
- A facial cutaneous lesion in an immunocompetent child, initially misdiagnosed and repeatedly excised, was confirmed as cutaneous malakoplakia after a 2-year chronic course.
- Histopathology revealed granulomatous inflammation with phagocytic histiocytes containing Michaelis-Gutmann bodies, and cultures identified Streptococcus group B.
- The lesion resolved following a 4-month course of oral antibiotics, including trimethoprim-sulfamethoxazole.
Findings:
- Purely cutaneous malakoplakia is exceptionally rare, accounting for only 4% of reported cases, with most occurring in the genitourinary tract.
- The histopathological hallmarks include phagocytic macrophages with intracytoplasmic granules and Michaelis-Gutmann bodies.
- Successful treatment was achieved with prolonged antibiotic therapy targeting intracellular bacteria.
Implications:
- This case underscores the importance of considering cutaneous malakoplakia in pediatric dermatology, even in immunocompetent individuals.
- Effective management relies on histopathological diagnosis and protracted antibiotic treatment with macrophage-penetrating drugs.
- Recurrence after surgical excision is possible, emphasizing the need for appropriate medical therapy.