An ulcerated violaceous nodule on the thigh

Abstract

A 42-year-old woman presented with a plaque on the medial aspect of her thigh lasting for one month. She reported bloody and purulent discharge, fevers, and debilitating local pain. She had a history of renal transplant for chronic idiopathic glomerulonephritis, for which she received prednisone, mycophenolate mofetil, and tacrolimus, and also a history of antiphospholipid antibody syndrome, for which she received warfarin treatment. Examination revealed a 7-cm ulcerated violaceous nodule (Fig 1). An incisional biopsy was obtained for diagnostic clarification (Figs 2 and 3). Tissue culture grew 31 Escherichia coli, 31 Pseudomonas aeruginosa, and 11 Bacteroides fragilis.

Cutaneous malakoplakia arising on the ankle of a patient with pyoderma gangrenosum

“…Malakoplakia most frequently occurs in adult males involving the urogenital tract (such as the bladder, ureters, kidney, and male prostate) and clinically presents with urinary symptoms and/or recurrent E. coli bladder infections. Malakoplakia is extremely uncommon in the skin, although various cutaneous sites have been documented in the literature and they include: scalp, forehead, cheek, neck, axilla, buttocks, perianal region, and thigh 9–18 . Other clinical settings in which cutaneous malakoplakia has been reported include patients with connective tissue disease, sarcoidosis, diabetes mellitus, and HIV/AIDS 17 …”

“…although various cutaneous sites have been documented in the literature and they include: scalp, forehead, cheek, neck, axilla, buttocks, perianal region, and thigh. [9][10][11][12][13][14][15][16][17][18] Other clinical settings in which cutaneous malakoplakia has been reported include patients with connective tissue disease, sarcoidosis, diabetes mellitus, and HIV/AIDS. 17 Due to the variability in clinical presentation, cutaneous malakoplakia is best diagnosed using characteristic histopathologic features seen in a skin biopsy.…”

“…Treatment for cutaneous malakoplakia includes chronic systemic antimicrobials with intracellular penetration, such as fluoroquinolones and trimethoprim sulfamethoxazole, although the exact agent should ideally be chosen based on tissue culture and sensitivities. 9,12,18 Surgical excision can also be combined with systemic antimicrobial therapy, such as when the skin lesion is small in size and/or refractory to initial monotherapy with antibiotics. In general, the overall prognosis for malakoplakia is good with initiation of the appropriate treatment.…”