Title : An atypical case of a Helicobacter infection in an immunocompromised host
Abstract:
In the realm of gastrointestinal diseases, Helicobacter pylori is a well-known pathogen associated with several conditions, such as certain gastric malignancies and peptic ulcer disease. Cutaneous involvement of Helicobacter, however, is exceedingly rare but has been reported in the past. Immunocompromised hosts are particularly susceptible to such atypical presentations, in large part due to their impaired immune response. Given the extensive differential of many cutaneous lesions, recognizing Helicobacter as a possible culprit may help limit excessive diagnostic testing. Here, we present a case of cutaneous Helicobacter in an immunocompromised patient that was successfully diagnosed and treated.
A 45-year-old man with a history of multiple sclerosis on chronic immunosuppression with rituximab presented with bilateral lower extremity ulcers and swelling. Before presenting to us, he was treated with an array of topical creams and compression devices, but the skin failed to heal completely with these treatments. By the time he presented to us, he had already completed several diagnostic tests, including Doppler ultrasounds of both lower extremities, a CT of his abdomen and pelvis, and an image-guided biopsy. The results of these tests were largely unremarkable, with the biopsy showing evidence of fibroblastic proliferation with acute and chronic inflammation suggestive of a reactive process.
When he presented to our clinic, he continued to endorse similar ulcers, rashes elsewhere across his body, and generalized fatigue. He denied any fevers, chills, weight loss, abdominal pain, headaches, numbness, weakness, dysuria, or melena. His exposure history was notable for extensive traveling, including across the United States, Africa, Asia, Europe, and the Middle East. His physical exam revealed a hypopigmented ulcerative lesion on his right shin and multiple subcutaneous nodules on the left side. His labs were remarkable for a mildly elevated ESR and CRP.
Given his immunosuppressed state and the chronicity of his symptoms, we pursued further diagnostic testing, which included immunoglobulin levels, additional imaging, and a broad microbiological workup. From this workup, notable findings included a mildly decreased IgG level and a Karius test that detected Helicobacter. We then requested a broad range PCR to be completed on the original biopsy specimen, which also came back positive for Helicobacter. Subsequently, he was started on amoxicillin, doxycycline, and metronidazole and then transitioned to doxycycline and amoxicillin. Over the course of several weeks, he experienced a significant improvement in his symptoms, with near complete resolution.
As seen here, cutaneous Helicobacter infections can present insidiously in immunocompromised patients. Given the fairly nonspecific presentation, it’s important to maintain a high index of suspicion for this and test with molecular diagnostics. Targeted antibiotic therapy can lead to successful resolution of symptoms and prevent further complications.
