Repositório RCAAP

Introduction: The antibiotic resistance in Neisseria gonorrhoeae has been considered an important public health problem worldwide, posing serious problems for its treatment in some countries. Aims: To overview the national and international antibiotic resistance reports on Neisseria gonorrhoeae. Material and Methods: Literature search in national and international scientific journals (the later indexed in PubMed/Medline and in English language). "Neis- seria gonorrhoeae antibiotic resistance" were used as keywords. Results: Third-generation cephalosporins (ceftriaxone and cefixime), alone or combined with azithromycin, replaced fluroquinolones as the first-line treatment for gonorrhea. Up to now, there were just a few reports on cephalosporin resistance. However, reports of an increase of the minimum inhibitory concentration (MIC) to cephalosporins, reflected by the decreased sensitivity to this class of antibiotics, be- came frequent. The azithromycin resistance has been reported in several countries. In Portugal, to date, there are no described cases of cephalosporin resistance; however, azithromycin – resistant Neisseria gonorrhoeae isolates and re- duced sensitivity to cephalosporins have already been described. Conclusion: New therapeutic agents are essential to overcome antibiotic resistance in Neisseria gonorrhoeae, as well as appropriate conducts by physicians, patients and sexual contacts of the later.KEYWORDS – Anti-Bacterial agents; Drug resistance, bacterial; Neisseria gonorrhoeae; Guideline. 

Cases report: Four patients (two men and two women) were submitted to wide surgical excision of basal cell carcinoma of the nose. For the reconstruction full-thickness skin grafts were collected in the preauricular region. A tension-free primary closure was achieved at the donor sites. All skin grafts survived. The aesthetical results were good. Comments: Full-thickness skin grafts collected in the preauricular region provide distinctive aesthetics results, being a good option for the reconstruction of surgical defects of the dorsum, tip and sidewalls of the nose. KEYWORDS – Nose; Nasal neoplasms; Nasal surgical procedures; Skin transplantation. 

A exostose subungueal é um tumor ósseo benigno incomum que afecta especialmente os adolescentes e adultos jovens. Tem como localização preferencial o 1o dedo do pé, muito provavelmente por este estar frequente- mente exposto ao traumatismo, factor etiológico conhecido. O diagnóstico diferencial inclui, para além de tumores malignos, verruga viral, fibroma, granuloma piogénico ou osteocondroma subungueal. O diagnóstico é confirmado por radiografia demonstrando-se o crescimento ósseo anormal. Descrevem-se os casos clínicos de duas jovens que recorreram à nossa consulta por exostoses dos dedos dos pés, assim como a técnica cirúrgica utilizada em cada um dos casos. O tratamento da exostose subungueal é exclusivamente cirúrgico. As técnicas de excisão são múltiplas e estão docu- mentadas por especialistas de várias áreas. Existe concordância na importância fundamental da excisão de todo o tumor de forma a evitar as altas taxas de recorrência. PALAVRAS-CHAVE – Exostoses; Unhas. 

Background: Coexistence of lichen sclerosus and morphea, in most cases with extragenital localization, has been reported in the literature. Case report: A 58-year-old woman presented in 1998 with sclerotic and atrophic linear plaques on the right hemibody, whose histopathological study was compatible with linear morphea. Nine years later, on the residual atrophic areas, small whitish lesions grouped into plaques developed and histology was compatible with lichen sclerosus. Simultaneou- sly, ill-defined, pearly white plaques occurred in the vulva conditioning atrophy of the labia minora, compatible also on histology with genital lichen sclerosus (GLS). A good response to topical corticosteroids was observed. Discussion: In a recent study 38% of patients with morphea also suffer from GLS, suggesting that the two diseases may have common mechanisms or that GLS represents the genital manifestation of morphea. We emphasize the need to examine the genitalia of patients with morphea due to morbidity and the risk of squamous cell carcinoma associated with GLS. KEYWORDS – Genital diseases; Female; Lichen sclerosus et atrophicus; Scleroderma, localized; Skin diseases. 

The authors report the case of a 58 years old patient, with psoriasis, psoriatic arthritis and Crohn's di- sease, who developed two episodes of pulmonary tuberculosis during the immunobiological therapy. While treating the second episode of pulmonary tuberculosis, it was decided to reinstate the use of immunobiological, given the severity of the Crohn's disease and the poor control of psoriasis with other drugs, evolving with good results in controlling the activity of Crohn's disease, psoriasis and psoriatic arthritis. KEYWORDS – Psoriasis; Mycobacterium tuberculosis; Arthritis, psoriatic; Crohn disease; Immunologic factors. 

Erythema nodosum (EN) is a panniculitis that presents with painful erythematous nodular lesions, pre- ferentially located on the extensor surface of the legs. EN is generally self-limited and chronic or recurrent lesions are rare. Its most common causes are streptococcal pharyngitis, sarcoidosis, inflammatory bowel disease and tuberculosis. A 73-year-old woman presented with recurrent EN with a year of evolution, and the etiological investigation excluded the most frequent causes. The patient underwent upper endoscopy for epigastric pain complaints revealing a gastric infiltrative process. The biopsy was consistent with a diffuse large B-cell lymphoma. Although rare, the association between lymphoma and recurrent EN is described in the literature, and EN may precede de diagnosis of lymphoma by months. Non-Hodgkin lymphoma should therefore be considered in the etiology of EN, especially in cases of persistent or recurrent EN. KEYWORDS – Erythema nodosum; Lymphoma, non-Hodgkin. 

Pemphigus vulgaris is a rare autoimmune blistering disease affecting the skin and mucous membranes. In general, it has a severe course and may require long-term treatment with systemic corticosteroids and other immuno- suppressive drugs, which can lead to serious adverse events. Rituximab is a chimeric monoclonal antibody that targets the CD20 antigen found on B cells. Recently, there have been some reports documenting its use in the treatment of re- fractory pemphigus. The authors describe two clinical cases of pemphigus vulgaris refractory to conventional therapies that have been treated with rituximab and have achieved complete remission. In conclusion, our experience shows that rituximab is a valuable and safe option to treat severe and refractory pemphigus vulgaris KEYWORDS – Antibodies, monoclonal; Pemphigus. 

Benign cephalic histiocytosis is a type of non-Langerhans histiocytitic disorder. Of unknown etiology, is a self-healing disease, arising in childhood and is characterized by papular lesions primarily affecting the face. We describe a 10-month-old girl who presented with 6 months of evolution, yellow-red papules asymptomatic, on her face. The histological and immunohistochemical study showed the presence of a diffuse infiltration of histiocytes, throu- ghout the dermis, negative for the protein S100 and CD1a and positive for CD68. Given the diagnosis of benign cepha- lic histiocytosis, we chose an expectant attitude verifying complete regression after one year of follow-up. Since its description by Gianotti, et al. in 1971, only 40 cases were reported in the literature. KEYWORDS – Histiocytosis; Non-Langerhans-cell; Facial dermatoses; Skin diseases. 

Introduction: Merkel cell carcinoma (MCC) is a rare cutaneous malignancy which incidence has tripled in the last 20 years, because of new pathologic techniques. Its mortality rates exceed those of melanoma, with signi- ficant associated morbidity and loco-regional metastasis. Material and methods: The authors reviewed the literature in order to provide clinical practice guidelines for the diagnosis and treatment of MCC. Results: Recently the American Joint Committee on Cancer has developed a staging system (TNM), which divides the MCC into 4 stages, depending on the degree of aggressiveness of the tumor. Surgery is the treatment of choice in the MCC approach, with surgical margins ranging between 1-2cm depending on the characteristics of the primary tumor. Currently consensus is the benefit of sentinel node biopsy, and the status of the sentinel node the most important prognostic factor. Adjuvant radiotherapy to the tumor bed and lymph node basis is of particular importance when associated with radical lympha- denectomy. Despite being sensitive to chemotherapy, stage IV MCC has a poor prognosis, with questionable benefit of chemotherapy. Conclusions: It is important to keep a low threshold of suspicion for the CCM, in order to optimize the treatment of this aggressive tumor.  KEYWORDS – Carcinoma, Merkel cell; Sentinel lymph node biopsy; Neoplasm staging; Practice guidelines.

Introduction: patient safety is a growing concern in healthcare management. The main objectives of our work were the detection of potentially avoidable errors in the treatment of patients with melanoma and search for solutions to improve patient safety. Material and methods: FMEA (Failure Mode and Effect Analysis) was used for analysis of the potentially avoidable errors in melanoma surgery. Results: Failure to attend surgery or post treatment follow up and wrong site surgery were the most potentially dangerous procedural errors found in melanoma treat- ment. An informatic application was used to improve communication between the laboratory and the clinician and to avoid both failures to deliver a positive result to the patient and loss of follow up. Conclusions: dermatologists, working together with other healthcare workers, must actively search for opportunities to improve patient safety du- ring melanoma treatment. KEYWORDS – Patient safety; Melanoma; Role of informatics. 

Background: Primary hyperhidrosis is frequent and has significant psychological and socio-professional impact. Many of available treatments are ineffective or have considerable side effects. Botulinum toxin type A (BTX-A) has proven to be a safe and effective therapy in recalcitrant hyperhidrosis, albeit with limited efficacy on time. Material and methods: A retrospective study was performed, with demographic and clinical data of the patients with hyperhidro- sis treated with BTX in our department in the period between June 2007 and June 2012. The severity of the disease was established by the Hyperhidrosis Disease Severity Scale. The hyperhidrotic area was identified by using a modification of the minor’s iodine-starch test. BTX-A was administered at a dose of 50U per axila or palm. Results: Sixteen patients were treated, 11 women and 5 men, with an average age of 24 years. Nine had axillary and 7 had palmar hyperhidro- sis, with an average HDSS of 3.22 and 3.57, respectively. In the first week after the treatment, there was a reduction of sweating that has remained for 16 to 26 weeks. In the fourth week after treatment, the HDSS was 0.56 and 1.14 (axillary and palmar hyperhidrosis patients, respectively). After a 15 to 16 months follow-up, there were no significant side effects.Conclusions: Treatment with BTX-A is relatively easy to perform and improves substantially the quality of life. In our experience, BTX-A proved to be an effective and safe therapy of primary hyperhidrosis.KEYWORDS – Botulinum toxins; Type A; Hyperhidrosis. 

Introduction and Objectives: Phototherapy (UVB alone or in combination with UVA) has been used suc- cessfully in the treatment of severe pruritus associated with chronic kidney disease (CKD) and human immunodeficiency virus (HIV) infection. This study was performed to evaluate the efficacy and safety of a combination of broad band (BB) - UVB and UVA in the control of intractable renal and HIV pruritus.Material and methods: Eighty three patients (55 with renal pruritus and 28 associated with HIV infection) were included in this retrospective study. Light treatments with UVAB were given three times a week. The initial UVB dose was 20 to 30mJ/cm2 (70% of the MED) increased by 30 mJ/cm2 at each subsequent session, until erythema or relief of pruritus was obtained. The initial and subsequent UVA doses were selected based on the skin type and the upper limit was set at 6J/cm2.Results: The 55 patients with renal pruritus (33 males and 22 females) had a mean age of 57,7 years, a mean duration of CKD of 8,7 years and pruritus for a mean of 27,8 months; they received an average of 11,1 treatments, 22,9J/cm2 of UVA and 1900mJ/cm2 of UVB; the patients reported appreciable relief of pruritus after 5 treatments and complete resolution at the end of the phototherapy cour- se; the patients were still in remission after a mean follow-up period of 11,2 months. The 28 patients with HIV infection (18 males and 10 females) had a mean age of 40,8 years, were discovered to be seropositive for a mean period of 2,5 years, generalized itch for 13,4 months and a mean CD4 cell count of 177 cells/μL; they received an average of 12,1 treatments, 24,3J/cm2 of UVA and 2000mJ/cm2 of UVB; 21 patients reported appreciable relief of pruritus after 5 treat- ments with complete resolution at the end of the phototherapy course and still in remission after a mean follow-up period of 13,4 months. The only side-effects reported were moderate hyperpigmentation and slight erythema. No deleterious effects on immune function were detected in the HIV-infected patients.Conclusion: The results suggest that combined BB-UVB and UVA is efficacious and safe in the control of intractable renal and HIV pruritus.KEYWORDS – AIDS-related opportunistic infections; HIV infections; Pruritus; Ultraviolet therapy. 

Infection with human papillomavirus (HPV) is one of the most common sexually transmitted infections, but is frequently asymptomatic and transitory. Nevertheless, HPV anogenital infections can have serious clinical consequences, and its role in the development of cer- vical cancer has already been established. Recently, it has also been implicated in other anogenital cancers, such as the anal, vulvar, vaginal and penile cancer, as well as nonanogenital cancers, like head and neck cancers. Genital warts are benign lesions and represent the most common clinical presentation of HPV anogenital infection. Although they are most often associated with non-oncogenic HPV types, increasing evidence suggests an association between these lesions and both anogenital and nonanogenital malignant neoplasms. KEYWORDS – Papillomavirus infections; Condylomata acuminata; Neoplasms. 

Introduction: In the late 70’s gonococcal infection decreased in most Western European Countries. In the 90’s there has been an important increase in the incidence of the disease, mostly in some higher risk groups. Material and methods: This is a retrospective study based in the population attending the STD Clinic of Centro de Saúde da Lapa, between January 2007 and December 2011 (5 years). We assessed epidemiological data, the prevalence of Neisseria gonorrhoeae infection and associated sociodemographic factors. Results: During the study period a total of 9068 patients attended the Clinic. Gonococcal infection was diagnosed in 386 (4.3%) patients (335 men and 51 women, median age of 30). In 2007 there were 66 cases of gonorrhoea, 57 cases in 2008, 106 cases in 2009, 67 cases in 2010 and 90 cases in 2011. The most frequent localization of infection was the urethra with 312 cases, followed by uterine cervix in 51 women and rectus in 30 men, with only 2 infections in the oropharynge. Co-infection was found with Chlamydia trachomatis in 80 cases and HIV in 50 patients.Conclusions: Gonococcal infections diagnosed in the STD Clinic of Centro de Saúde da Lapa have gradually increased in the last decade, with most cases diagnosed in 2009. N. gonorrhoeae infection is a current problem, far from being eradicated and with new challenges regarding treatment.KEYWORDS – Neisseria gonorrhoeae; Sexually transmitted  diseases.   

The concept of neutrophilic dermatoses encompasses several entities that share clinical and histological aspects. Recently described, neutrophilic dermatosis of the dorsal hands is a disease with unknown etiology that clini- cally resembles a localized variant of Sweet syndrome, with lesions predominantly located in the back of the hands and with variable presence of systemic symptoms accompanying. From the histological point of view, it is characterized by a dense neutrophilic inflammatory infiltrate with vasculitis aspects being inconsistent. The authors present two patients with neutrophilic dermatosis of the dorsal hands and discuss its clinical, laboratory and histopathological aspects and therapeutic options available. The neutrophilic dermatosis of the dorsal hands is an evolving concept, which shares many common aspects with other neutrophilic dermatoses, suggesting a continuous spectrum of this group of diseases KEYWORDS – Hand dermatoses; Sweet syndrome. 

Introduction: Sweet’s syndrome is a neutrophilic dermatosis with acute cutaneous lesions as erythematous edematous plaques and nodules. Other alterations include fever, peripheral leukocytosis, arthralgia, myalgia, cephalea and ophthalmic, oral cavity and internal organs involvement. The purpose of this article is to discuss the clinical condition of the patient, as well as the diagnostic criteria, the approach used to investigate possible associated condi- tions and the different forms of treatment. Case Report: It is about a 45-year old white woman with idiopathic Sweet’s syndrome treated with glucocorticoids. Physical examination revealed erythematous and edematous plaques with pseu- dovesicular appearance on the face, trunk, upper and lower limbs. Histopathology revealed edema, dense neutrophilic infiltrate, leukocytoclasia and extravasation of erythrocytes in the upper dermis.Discussion: Sweet’s syndrome it might be related to the use of medication, pregnancy, inflammation, infection or malignancy. The most commonly associated neoplasias consist of hematological malignancies, particularly acute myeloid leukemia. Although glucocorticoids cons- titute the treatment of choice for Sweet’s syndrome, other therapeutic options exist.KEYWORDS – Sweet syndrome; Paraneoplastic syndromes; Skin diseases. 

Ashy dermatosis or erythema dyschromicum perstans (EDP) is a clinical syndrome with a controversial classification. The condition is rare in Brazil. It was initially reported in El Salvador but has also been found in several South American countries and in other regions of the world. Its etiology is unknown; however, some authors believe that it represents a diffuse presentation of fixed drug eruption, while others consider it to be a variant of lichen planus pigmentosus in view of the similar histopathological findings. Clinically, the condition presents with lesions in the form of numerous gray macules of varying sizes. There is no effective treatment to date; however, benefits have been repor- ted with the use of clofazimine. In this report, the authors describe a case of ashy dermatosis associated with the use of serotonin-specific reuptake inhibitors. KEYWORDS – Skin diseases; Erythema; Hyperpigmentation; Drug eruptions; Lichen planus. 

Dry skin is a frequent reason for consultation in dermatology. Its treatment involves the identification of the underlying cause. The authors describe the case of a 49-year-old male patient, who was referred to a dermatological consultation due to severe dry skin lasting for 4 months. He also reported intense pruritus, oral xerosis and asthenia. Eight months ago, the patient had been submitted to total thyroidectomy, and was taking since then only calcium without thyroid hormones. At presentation, the patient had a deep voice, eyelid edema, macroglossia, severe generalized xerosis with areas of eczema craquelé on the limbs, dorsal follicular hyperkeratosis, hiperlinearity of the hands, yellowish tint palmoplantar skin and bradycardia. Analytically, an elevation of transaminases, hypercholesterolemia, hypertriglyceridemia, high level of TSH and decreased T3 and T4 recorded. This case illustrates the rich semiology of a cause of an iatrogenic endocrino- logical cause of severe xerosis. KEYWORDS – Skin diseases; Thyroid hormones; Hypothyroidism. 

Cutaneous larva migrans is one of the most frequent dermatoses among travelers returning from the tro- pics. Ancylostoma braziliense, a larva that resides in the intestines of infected dogs and cats, is the most frequent agent of the disease. Humans are affected when they contact with contaminated soil. We present the case of a Portuguese 39-year-old teacher that after returning from vacation in northeastern Brazil, deve- loped a skin eruption localized to the 4th interdigital fold and adjacent portion of the dorsum of the feet, consisting of multiple erythematous, pruritic and serpiginous cutaneous trails, suggestive of cutaneous larva migrans. Complete cure was achieved after Albendazole therapy. Due to the increased frequency of migration flows, tropical dermatoses may become more common in temperate coun- tries. We emphasize the importance of tourists counseling and the use of protective footwear to prevent this disease. KEYWORDS – Larva migrans; Ancylostoma; Skin. 

Cutaneous larva migrans is common in tropical and sub-tropical countries and is caused by the migration of nematode ́s larvae in the skin. The diagnosis is made primarily with the epidemiological characteristics of the derma- tosis and its clinical semiology. Usually the treatment is successful with albendazole or ivermectin. We describe the case of a 54-year-old woman returned from holidays in Jamaica 15 days ago. The patient had on site, a well delimited, 2mm wide erythematous papule on the external face of the left foot, progressing along the plant throu- gh a serpiginosum track until reaching the internal face of the foot. She denied fever or other symptoms. Clinically the dermatosis was very suggestive of cutaneous larva migrans and the patient was treated with albendazole. This case serves to remind an uncommon dermatosis in Portugal. It also intends to alert to the early recognition of this skin infestation. Although self-limiting, this disease is cause of great anxiety for the patients. KEYWORDS – Larva migrans; Skin diseases.