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case_images: Ulcerated, punctate erosions with ragged edges on the patient's back typical of Morgellons disease lesions.
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case_images: In June 2015, she presented with unresolved gynecological symptoms and, in addition, had developed ulcerated, punctate erosions with ragged edges on her back (Figure 1).
case_images: (A-C) Expanding annular rashes on the patient's hands, back and leg, with a raised, advancing, erythematous border consistent with secondary erythema migrans (EM) rashes.
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case_images: The patient then relapsed with the development of annular rashes on her hands, legs, back and abdomen (Figure 2A-C).
case_images: Secondary EM rash revealing embedded fibers (arrow) consistent with Morgellons disease. 100X original magnification.
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case_images: Microscopic examination of the rashes at 100X magnification revealed blue embedded fibers consistent with MD (Figure 3).
case_images: Gross morphology of a biopsy taken from the advancing edge of a lesion on the hand, revealing embedded and protruding blue and white fibers. 100X original magnification.
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case_images: A biopsy taken from the advancing edge was formalin-fixed and forwarded to McClains Laboratories for histological staining (Figure 4).
case_images: Sections stained with H&E exhibiting parakeratotic hyperkeratosis, spongiosis, and hemorrhage. 200X original magnification.
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case_images: The stratum spinosum and stratum basale demonstrated disarray and some degeneration with the formation of vacuoles and apoptotic bodies (Figure 5).
case_images: (A) Dieterle silver stain of spirochetes (arrow) among basal keratinocytes. 1000X original magnification. (B) Anti-Bb immunostained section showing positive-stained Borrelia organisms consistent with cystic morphology mixed with negatively stained bacteria within bacterial aggregates. 1000X original magnification.
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case_images: Dieterle staining revealed bacterial aggregates within the hyperkeratotic stratum corneum with both long extracellular spirochetes and intracellular organisms among the keratinocytes in the stratum basale (Figure 6A). These aggregates displayed both positive and negative staining, indicating that the aggregates were composed of a mixture of different bacterial species (Figure 6B).
case_images: (A) Anti-Bb immunostained section showing positively stained intracellular and extracellular organisms (arrow) associated with keratinocytes of the stratum basale and stratum spinosum. 1000X original magnification. (B) Anti-Bb immunostained section showing intracellular staining of organisms within lymphocytes (arrow) in a dermal infiltrate. 1000X original magnification. (C) Anti-Bb immunostained section showing positively stained organisms (arrow) in dermal glandular tissue. 1000X original magnification. (D) Anti-Bb immunostained control section of fungal-infected skin. 1000X original magnification.
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case_images: Positive intracellular and extracellular staining was prominent within the keratinocytes of the stratum basale and stratum spinosum (Figure 7A). The lymphocytes in dermal infiltrates and cells within dermal glandular tissue revealed positive anti-Bb intracellular staining (Figure 7B and C). Anti-Bb staining of fungal-infected skin served as a negative control (Figure 7D).
case_images: (A) Gram stain of biopsy section showing Gram-positive cocci in superficial layer. 1000X original magnification. (B) Gram stain of biopsy section showing negative staining in deep layers. 1000X original magnification.
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case_images: Gram staining revealed Gram-positive cocci scattered on the superficial stratum corneum and in bacterial aggregates within the hyperkeratotic stratum corneum (Figure 8A). The deeper layers of the epidermis and dermis were devoid of Gram-positive organisms (Figure 8B).