A 14-year-old boy had suffered from Kawasaki disease. From 8 days before the first visit, his fever reached the 38 ℃ range, erythema of the limbs appeared 5 days before, and pustules appeared throughout the body 1 day before. Leukocytosis with leftward movement, elevated serum C-reactive protein, and mild jaundice were observed. The histopathological findings of the pustules showed subcorneal pustules with neutrophils. Echocardiography was normal. Gamma globulin and aspirin were administered, and desquamation was confirmed on the limbs. Pustules are the main diagnostic criterion of Kawasaki disease, but the frequency of reports of Kawasaki disease accompanied by pustules has been decreasing in recent years. It seems that an effective treatment regime has been established for Kawasaki disease and the therapy is usually started before the appearance of pustules. In older children, Kawasaki disease with small pustules is difficult to distinguish from acute generalized eruptive pustulosis, and the start of treatment tends to be delayed. If steroid alone is administered for Kawasaki disease, the risk of a coronary artery lesion increases. Therefore, prevention of the sequela of heart failure should be given priority.

An 85-year-old woman had presented scaly erythema on her palms and keratoderma on her soles for 60 years. Seven years previously, she had undergone surgical resection of squamous cell carcinoma (SCC) on her left palm. Scaly erythema was observed on both her palms and keratoderma was observed on her soles, prompting a diagnosis of palmoplantar eczema. Biopsies from the lesions of the palms and soles showed thin cords of epithelium that elongated downward and anastomosed with one another to form a lattice-like pattern including eccrine ducts in several areas. These findings led to a final diagnosis of multiple eccrine syringofibroadenoma (ESFA). Since the prior surgical specimen of SCC was accompanied by similar findings of ESFA, the malignant transformation of ESFA was considered to have caused the development of SCC. Although ESFA usually presents as a solitary, large hyperkeratotic nodule appearing on the extremities, it sometimes presents as palmoplantar keratoderma. Owing to a lack of clear demarcation, we treated this case with topical highly potent steroids and narrow-band ultraviolet B irradiation without particularly satisfactory effects. Because of the risk of malignant transformation, regular follow-up and close observation are warranted.

A 64-year-old man presented with a solitary mass lesion on his scalp. He had first noticed the lesion during his teenage years and it had enlarged gradually since then. A histopathological examination showed that the tumor had two distinctive structures, verrucous carcinoma (VC)-like and syringocystadenoma papilliferum (SCAP)-like patterns. In the latter structure, atypical cells were proliferated. Additionally, a transitional feature could be seen between two patterns. We diagnosed this case as syringocystadenocarinoma papilliferum (SCACP). SCACP, which is the malignant counterpart of SCAP, is an extremely rare adnexal neoplasm that has been described in fewer than 40 cases worldwide. SCACP typically appears as a red nodule or an inflamed plaque and usually develops on the scalp of elderly people within a long-standing lesion. Only a few cases have been reported to have SCACP with a region showing squamous differentiation, and there have been no reports of SCACP predominantly comprised of VC. Unlike SCAP and VC, SCACP may undergo lymph node metastasis and local recurrence. Because of the large difference in prognosis between SCACP and SCAP or VC, it is important to distinguish SCACP accurately by observing the whole image. We report a first case of SCACP showing the histological features of both adenocarcinoma and VC.

An 84-year-old man who had undergone a right kidney resection because of renal carcinoma was referred to our department with the complaint of a subcutaneous tumor in the left buttock. The lesion showed fluorodeoxyglucose accumulation on PET-CT imaging and was suspected to be a skin metastasis from the renal carcinoma. Histopathologic examination of the biopsied specimen revealed scattered spindle and oval cells with mild atypical nuclei in the mucin matrices,which were suggestive of a mucin-producing fibrosarcoma-like tumor. A detailed examination of the resected tumor led to a diagnosis of low-grade myxofibrosarcoma characterized by positivity for vimentin and CD34 but negativity for S100 and smooth muscle actin. As the residual tumor was suspected, the additional resection with a 3-cm margin at the sub-fascial level was performed. We here describe a case of myxofibrosarcoma in which the histological and immunohistochemical analysis of the resected specimen led to the adequate diagnosis and therapy.

Toxoplasmosis is a zoonosis caused by Toxoplasma gondii (T. gondii), which is an intracellular parasitism protozoan. Infection with T. gondii is mainly acquired by the ingestion of food or water contaminated with oocysts shed by cats or by eating undercooked or raw meat containing tissue cysts. Although most infected patients are asymptomatic, toxoplasmosis can manifest as lymphadenopathy in adults, especially in the cervical area. We report a case of axillary lymphadenopathy caused by infection with T. gondii. A 28-year-old man visited our hospital with a subcutaneous tumor of the left axilla. Imaging examinations showed multiple lymphadenopathy in the left axillary area. The histopathological findings of the biopsied axillary lymph nodes indicated reactive follicular hyperplasia with an enlarged germinal center and epithelioid cell cluster in the paracortical area. Serological tests also revealed elevated IgM and IgG antibodies against Toxoplasma. Based on these results, we diagnosed this case as having toxoplasmosis. The swollen lymph nodes spontaneously regressed without treatment. We emphasize that dermatologists should consider this infection when encountering lymph node swellings in a confined area.

A 68-year old woman suffering from chronic renal failure and liver eirrhosis had noted multiple subcutaneous abscesses on the backs of both hands and her right foot since March. The abscesses had initially been treated in another division; however, as they did not improve, she was transferred to our division in July. Deep mycosis or a nontuberculous mycobacterial infection was suspected based on the results of a histological examination. Because the β-D glucan level was high and fungi were detected in the abscess, the patient was diagnosed to have multiple subcutaneous abscesses due to deep mycosis and treated with antifungal medicines. Thereafter, the β-D glucan level normalized; however, her rashes gradually worsened. Bacterial cultures were repeated, and culture of the pus taken from an abscess on the hand finally revealed Mycobacterium chelonae (M. chelonae) on culture plates for usual bacteria as well as on a Sabouraud glucose agar plate. Based on the clinical course and these findings, the patient was ultimately diagnosed to have nontuberculous mycobacterial infection due to M. chelonae in association with deep mycosis and treated with additional clarithromycin and clindamycin. Although the rashes had nearly disappeared by early November, the patient died several days after. Given her high blood β-D glucan levels, the patient had been treated for multiple subcutaneous abscesses due to deep mycosis, but the rashes showed no improvement. The causative bacteria had not been identified despite repeated bacterial cultures, but the present case was ultimately diagnosed as multiple subcutaneous abscesses due to M. chelonae infection, as the bacteria grew on plates meant for non-mycobacteria. The present course underscores the importance of repeating bacterial cultures when encountering non-healing multiple subcutaneous abscesses in potentially immunosuppressed patients, while always bearing in mind the possibility of a non-tuberculous mycobacterial infection.

Mycobacterium chelonae (M. chelonae) is widely distributed in the environment and particularly infects immunosuppressed patients. Its infection is characterized by various and multiple cutaneous lesions. In the present case, an elderly patient with long-term use of immunosuppressive agents had a relapse of cutaneous M. chelonae infection 8 months after treatment. This case was considered to involve latent infection of M. chelonae that developed resistance to antibiotics. Cutaneous M. chelonae infection has often been treated by antibiotic monotherapy. However, some cases that developed resistance to clarithromycin, a key drug for treating this infection, have been reported, so it is recommended that treatment proceed via a combination of antibiotics. Case reports of cutaneous M. chelonae infection are increasing, so further studies on the choice of antibiotics, and the duration and endpoint of treatment are required.

Patient 1: A five-year-old boy. He had tinea on the right cheek that was improved for a while by the topical application of antifungal agents, but red papulae later appeared again the same site during the treatment. Ectothrix parasitism was found on lanugo hairs that were collected and subjected to KOH microscopic examination. Patient 2: A seven-year-old girl (an elder sister of patient 1). Scaling erythema was found on her right forehead, right upper eyelid, and right eyebrow. KOH microscopic observation of hard hairs within the erythematous area identified fungal mycelia coiling around the hairs. Microsporum canis (M. canis) was isolated from both patients. Since M. canis was isolated from 3 of the 10 cats kept by this family, these cats were speculated to be infection sources. The symptoms of both patients improved after treatment with a combination of topical lanoconazole cream and oral terbinafine hydrochloride for 4 weeks. Since M. canis has a high affinity for hairs, this infection may be refractory to topical antifungal agents and recur during treatment with topical antifungal agents alone. Therefore, it should be kept in mind that some patients infected with M. canis require combined treatment with topical and oral antifungal agents.