Carmen Sophia T.

Rubia Medicine 3-A Advance Pathology

Dr. Maita Mojado

Case Report:
Toxoplasmosis Presenting as Nonhealing Cutaneous Ulcer
A 64-year-old female presented to the Dermatology Outpatient Department (OPD), with a
nonhealing ulcer over dorsum of the left hand for one year. The patient did not have any systemic
diseases.

I. Identifying data
• 64-year-old female, a retired teacher resides in West Oakland, Pittsburgh.
II. Chief complaint
• A nonhealing ulcer over dorsum of the left hand
III. History of present illness
• The patient presented to the Dermatology Outpatient Department, with complaints of a
nonhealing ulcer over dorsum of the left hand for one year. The lesion started as a small
papule which over time increased in size and got ulcerated. On examination, there is crusted
plaque with oozing pus mixed with blood with granulation tissue at the base of size 3 x 3 cm.
An incisional biopsy of the lesion was sent for histological examination.

Ulcerated lesion in hand

IV. Past medical and surgical history

• There was no any history of diabetes, hypertension, and tuberculosis and no any history of
trauma over the site.
V. Personal and social history
• The patient is a retired high school teacher and lives with her also retired engineer husband
in a small bungalow house in West Oakland, Pittsburgh. They never had any child. They live
with a pet cat that she had acquired more than a year ago just several weeks before the
 lesion on her left hand appeared as the patient recalled. The patient tends a garden in her
backyard and does garden work almost every day. She occasionally teaches piano as her
way to spend her free time from retirement.
VI. Pertinent positives/negatives of medical history
• The patient did not have any systemic diseases and no history of trauma over the site of the
lesion.
VII. Review of systems
• General: Has gained 10 lbs in the past 4 years.
• Skin: No rashes except the ulceration on the dorsum of her left hand.
• HEENT: Head: no history of head injury. Eyes: Reading glasses for 10 years, last checked 1
year ago. No symptoms. Ears: Hearing good. No tinnitus, vertigo, infections. Nose, sinuses:
Occasional mild cold. No hay fever, sinus trouble. Throat (or mouth and pharynx): Some
bleeding of gums recently. Last dental visit 3 months ago. No canker sores.
• Neck: No lumps, pain, discharge. No swollen glands.
• Breast: No lumps, pain discharge. Does self-breast examination sporadically.
• Respiratory: No cough, wheezing, shortness of breath. Last chest x-ray, 1995; unremarkable.
• Cardiovascular: No known heart disease or high blood pressure; last blood pressure taken
during the visit. No dyspnea, orthopnea, chest pain, palpitations. Has never had an ECG.
• Gastrointestinal: Appetite good; no nausea, vomiting, indigestion. Bowel movement about
once daily, sometimes has hard stools for 2 to 3 days; no diarrhea or bleeding. No pain,
jaundice, gallbladder or liver problems.
• Urinary: No frequency, dysuria, hematuria, or recent flank pain; nocturia x 1, large volume.
Occasionally loses urine when coughing.
• Genital: No vaginal or pelvic infections. No dyspareunia
• Peripheral vascular: No varicose veins, no swollen ankles, and no leg pain.
• Musculoskeletal: Mild low backaches, often at the end of the day; no radiation into the legs.
No other joint pain.
• Psychiatric: No history of depression or treatment for psychiatric disorders.
• Neurologic: No fainting, seizures, motor or sensory loss. Memory is good.
• Hematologic: Except for bleeding gums, no easy bleeding. No anemia.
• Endocrine: No known thyroid disorders or heat or cold intolerance. No symptoms or history
of diabetes.
VIII. Vital signs and physical examination
• The patient is a well-appearing woman, well-groomed but slightly conscious with her left
hand. Height is 5’ 4’’, weight 121 lb, BP 120/80, HR 72 and regular, RR 16, temperature
37.5⁰C.

Skin: A noticeable 3 x 3 cm crusted plaque with oozing pus mixed with blood and
granulation tissue on the dorsum of the left hand. Palms cold and moist, but good color.
Scattered cherry angiomas over upper trunk. Nails without clubbing, cyanosis.
HEENT: Head: Hair of average texture. Scalp without lesions, normocephalic/atraumatic.
Eyes: Vision 20/30 in each eye. Visual fields full by confrontation. Conjunctiva pink; sclera
white. Pupils 4 mm constricting to 2 mm, round, regular, equally reactive to light.
Extraocular movements intact. Disc margins sharp, without hemorrhages, exudates. No
 arterial narrowing or A-V nicking. Ears: Wax partially obscures right tympanic membrane;
left canal clear, TM with good cone of light. Acuity good to whispered voice. Weber midline.
AC>BC. Nose: Mucosa pink, septum midline. No sinus tenderness. Mouth: Oral mucosa pink.
Several interdental papillae red, slightly swollen. Dentition good. Tongue midline, no
ulcerations. Posterior pharyngeal exudates without tonsillar enlargement.
Neck: Neck supple. Trachea midline. Thyroid isthmus barely palpable, lobes not felt.
Lymph nodes: Small (<1 cm), soft, nontender, and mobile posterior cervical nodes
bilaterally. No epitrochlear or axillary nodes. Several small inguinal nodes bilaterally, soft
and nontender.
Thorax and lungs: Thorax symmetric with good excursion. Lungs resonant. Breath sounds
vesicular with no added sounds. Diaphragms descend 4 cm bilaterally.
Cardiovascular: Jugular venous pressure 1 cm above the sternal angle, with head of
examining table raised to 30⁰. Carotid upstrokes brisk, without bruits. Apical impulse
discrete and tapping, barely palpable in the 5th left interspace, 8 cm lateral to the midsternal
line. Good S1, S2; no S3 or S4. No systolic and diastolic murmurs.
Breast: Pendulous, symmetric. No masses; nipples without discharge.
Abdomen: Protuberant. No scars. Bowel sounds active. No tenderness or masses. Liver span
7 cm in right midclavicular line: edge smooth, palpable 1 cm below right costal margin.
Spleen and kidneys not felt. No CVAT.
Genitalia: External genitalia without lesions. Vaginal mucosa pink. Cervix pink, nulliparous,
and without discharge. No cervical or adnexal tenderness.
Extremities: Warm and without edema. Calves supple, nontender.
Peripheral vascular: No edema on ankles. No varicose veins. No stasis pigmentation or
ulcers. Brisk pulses.
Musculoskeletal: No joint deformities. Good range of motion in hands, wrists, elbows,
shoulders, spine, hips, knees, ankles.
Neurologic: Mental status: Tense but alert and cooperative. Thought coherent. Oriented to
person, place, and time. Cranial nerves intact.
Motor: good muscle bulk and tone. Strength 5/5 throughout. Romberg negative.

IX. Pertinent physical examination findings

• Skin: A noticeable 3 x 3 cm crusted plaque with oozing pus mixed with blood and
granulation tissue on the dorsum of the left hand.
• Neck: Lymph nodes: Small (<1 cm), soft, nontender, and mobile posterior cervical nodes
bilaterally.
X. Differential diagnosis
• CMV, Epstein-Barr virus, or HIV infections
• Rickettsial diseases (RMSF)
• Secondary syphilis
• Meningococcemia
XI. Diagnostic/laboratory work up (images and microscopic features)
• An incisional biopsy of the lesion was sent for histological examination which showed
epidermis lined by keratinized stratified squamous epithelium with parakeratosis, plasma
crusting and focal neutrophilic infiltration, and pseudocarcinomatous hyperplasia. Dermis
revealed suppurative to early plasma cell granulomas, along with eosinophils, macrophages,
multinucleated giant cells, and focal abscess formation.

H&E section (100x magnification) revealing surface ulceration and crusting with dense
inflammatory cell infiltrates in the dermis, at places forming pocket abscess.
 • Crescent-shaped organisms with a pointed anterior end and rounded posterior end were seen in
the dermis with morphological resemblance to tachyzoites of Toxoplasma gondii which were
positive for Periodic Acid Schiff (PAS) but negative for Silver Methenamine (SM)

(a, b) Tachyzoites of Toxoplasma, highlighted by PAS stain (400x magnification).

XII. Discussion
• Dermatologic manifestations of acute acquired toxoplasmosis in immune-competent are
considered rare. It is usually found in patients with a compromised immune system, such as
transplanted patients or patients having acquired immune deficiency syndrome (AIDS).

Humans usually acquire this infection through ingestion of oocysts deposited in soil or litter
pans of cats or by eating meat from chronically infected animals or through reactivation of a
previous latent infection following HIV infection and transplacentally via tachyzoites. Our
patient gives the history of cat handling at home.

There are three infectious stages of T. gondii: the tachyzoites (in groups or clones), the
bradyzoites (in tissue cysts), and the sporozoites (in oocysts).

The tachyzoite is often crescent-shaped, approximately 2 by 6 μm, and with a pointed

anterior (conoidal) end and a rounded posterior end. The nucleus is usually situated toward
the central area of the cell and contains clumps of chromatin and a centrally located
nucleolus.

During acute infection, rapidly multiplying “tachyzoites” occupy intracellular vacuoles;

parasitized host cells are eventually destroyed. During chronic infection, the slowly
multiplying organism “bradyzoites” store PAS-positive material and get tightly packed in
“cysts.”
 In the case above, the stained tissue sections revealed crescentic structures that were PAS-
positive.

Thus, a diagnosis of cutaneous toxoplasmosis was made, and the patient was put under
ivermectin therapy, with subsequent healing of the lesion.

XIII. Final diagnosis

• Primary cutaneous toxoplasmosis presenting with chronic nonhealing ulcer.

References
M. Adhikari, S. D. (2020). Toxoplasmosis Presenting as Nonhealing Cutaneous Ulcer. Case Reports in
Pathology, 3 pages.

Mawhorter, S. D. (1992). Cutaneous Manifestations of Toxoplasmosis. Clinical Infectious Diseases, 1084–

1088.