Disseminated Botryomycosis: A Rare Presentation

August 2014 | Volume 13 | Issue 8 | Case Report | 976 | Copyright © 2014

Benjamin Bashline DO,a Megan Morrison DO,a James Ramirez MD,b and Ann LaFond MDc,d

aSt. Joseph Mercy Hospital, Ann Arbor, MI
bDepartment of Pathology, St Joseph Mercy Hospital, Ann Arbor, MI
cDepartment of Dermatology, St. Joseph Mercy Hospital, Ann Arbor, MI
dMichigan State University, East Lansing, MI

Abstract

Botryomycosis is a rare chronic bacterial infection of the skin or viscera that resembles a deep fungal infection. Botryomycosis has two distinct patterns of infection, visceral and cutaneous, the latter being the most common. Cutaneous botryomycosis typically appears as a solitary plaque with superficial pustules. Histologically, bacterial colonies are arranged in a distinctive “bunch of grapes” pattern with surrounding eosinophilia, known as the Splendore-Hoeppli phenomenon. Here we report a case of an 83-year-old female with disseminated botryomycosis.

J Drugs Dermatol. 2014;13(8):976-978.

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INTRODUCTION

Botryomycosis is a rare chronic bacterial infection of the skin or viscera that resembles a deep fungal infection both clinically and histologically. The most commonly identified pathogen in human infection is Staphylococcus aureus, a gram-positive cocci, although several other organisms have been isolated, including Pseudomonas aeruginosa and Escherichia coli.1 On microscopic examination, there is a central cluster of bacteria with a surrounding area of eosinophilia, often resembling the sulfur granules of actinomycosis, referred to as the Splendore Hoeppli phenomenon.2 Botryomycosis has two distinct patterns of infection, visceral and cutaneous, the latter being the most common. Cutaneous botryomycosis involves the skin, subcutaneous tissues, muscle and bone. The extremities are the most common areas affected, with lesions in the trunk, face and perianal area reported less frequently. Visceral involvement has also been cited, with the lung as the most common infection.1

CASE REPORT

An 83-year-old African American woman presented with a 2-day history of worsening dyspnea and chest pain, as well a 1-week history of fever and painful crusted cutaneous lesions. She reported that multiple pustular lesions appeared over the course of a week on her face and right arm; several of which produced purulent drainage. The dyspnea had been getting progressively worse for a couple months prior to admission, and she had recently started oxygen supplementation. The patient had a past medical history of squamous cell carcinoma of the left lung, treated with chemotherapy and focused radiation 2 years ago. On presentation, a preliminary diagnosis of bacterial endocarditis was made by the primary team. Intravenous vancomycin was started and blood cultures were drawn. Transthoracic echocardiogram was nondiagnostic, and transesophageal echocardiogram was deferred due to the diminished respiratory capacity of the patient. Chest x-ray revealed an increased opacification of the left upper lobe. CT scan taken 1 month prior to admission showed a dense matted consolidation involving the left lobe.

On cutaneous examination, she had multiple small, tender, erythematous papules involving the right cheek, right upper eyebrow, left temporal hairline, tip of the nose, right pretibial area and right forearm, and right eyelid (Figures 1-3). A 3mm black eschar without surrounding erythema was present on the right thumb (Figure 4). Three 1cm erythematous papules with central black eschar were noted on the right forearm. The right pretibial area showed a 4mm black eschar with 1cm of surrounding erythema. A small 1mm pustule was seen on the nasal tip. On the second day of admission the patient noted a new tender lesion on her left labia majora, which was a 2mm skin colored tender papule with no discharge or necrotic center.

Bacterial culture was collected from the nasal tip pustule and biopsies from two lesions on the right forearm were taken for H&E and tissue cultures. The fresh tissue and nasal tip cultures consisted of gram-positive cocci arranged in clusters, which grew out Staphylococcus aureus. The biopsy revealed a dense and diffuse acute suppurative infiltrate. The center of the biopsy consisted of numerous bacterial colonies arranged in a distinctive “bunch of grapes” pattern (Figures 5-6). The blood cultures and PAS stains were negative.

DISCUSSION

Botryomycosis was first described by Bollinger in 1870, who noted the numerous granulomatous lesions that appeared after the castration of horses.1 Bollinger, and later Rivolta in

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