RCAAP Repository

.

Introduction: In addition to infection with Mycobacterium leprae, type 1 and 2 reactions represent acute inflammatory events in the chronic course of multibacillary leprosy, which may persist for long periods. Case Report: A young woman presenting borderline lepromatous leprosy and persistent type 2 reaction with difficult clinical conduction. Discussion: The case illustrates the diagnostic challenge in leprosy with a systemic inflammatory response, more expressive than the dermato – neurological features. The clinical, histopathological and therapeutic implications, as well as risk factors for reaction and also polymerase chain reaction 8 years after being discharged from treatment of multidrug therapy are discussed.

Etanercept is one of the biologic drugs approved for the treatment of psoriasis. Despite its wide use and proven efficacy, few cases of pulmonary toxicity have been reported.We present a patient with psoriasis vulgaris medicated with etanercept. Seven months after its start, the patient developed productive cough, with no fever or constitutional symptoms. The thoracic computerized tomography revealed a pattern of bilateral dense micronodules, with predominance in the superior lobes. After suspension of etanercept, there was symptomatic and imaging resolution, without the need for additional pharmacological treatment. We switched the biologic agent for ustekinumab, with goodtolerance and high efficacy.

Background: Skin diseases are common in Internal Medicine wards and often require observation by a dermatologist. This study intends to characterize the pattern of skin pathology in these patients and to evaluate the impact of dermatologists in their approach. Methods: A retrospective study was conducted. Dermatology observations over 46 months in Internal Medicine wards of Hospital Santo António dos Capuchos were analyzed. Patients’ conditions were classified according to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems. Results: 231 men and 217 women were observed, with an average age of 72.6 years. Stasis dermatitis and venous leg ulcers were the most common diagnosis. Discussion and Conclusion: The Dermatology team significantly reduced the number of undiagnosed patients. Our study reinforces the importance of dermatologists in the evaluation of inpatients with skin diseases.

.

Introduction: The homeless population has a higher risk for skin diseases. Life on the streets, associated with poor hygiene and eating habits, higher prevalence of addictive behaviors and psychiatric comorbidities make this population more susceptible to dermatosis. Our objective was to perform a dermatological examination, as complete as possible, of the homeless people accompanied by the Project of Intervention within the homeless population of Coimbra. After diagnosing a dermatosis, the adequate treatment is bought and started; whenever required, further management and follow-up are conducted in consultations of Dermatology. Furthermore, awareness and education for the importance of skin care is implemented for all the people observed. Material and Methods: The study was carried out between February 24, 2018, and January 19, 2019, evaluating individuals voluntarily enrolled who were living in temporary residence for homeless people in Coimbra (CAIS, Farol, Casa Abrigo Padre Américo) and supported by the team of Rua Reduz, by the Centro Municipal de Inserção Social and by the associations Sol Nascente and VHIDA +. In addition to the dermatological history and examination, demographic data, weight, height and medical history (including, mental illness, addictive behaviors and co-existence of HIV infection) were collected. Some participants also completed the DLQI questionnaire. Results: The 111 individuals evaluated had a mean age of 47.0 years, 83.8% were male, mostly single (60.7%) or divorced (29.9%); the Portuguese nationality was more prevalent (86.5 %). Globally, they had a lower level of education (63.9% with a level of education up to the 6th grade). The more prevalent skin diseases were eczema, tinea pedis, onychomycosis, seborrheic dermatitis and callosities. Among the 54 homeless individuals who completed the Dermatology Life Quality Index (DLQI) questionnaire, the majority (85.1%) reported little or no effect on quality of life. Conclusion: Most dermatoses were of mild severity and easy management, certainly due to the relatively good and healthy food and adequate hygiene care that we could observe in the homeless shelters, together with the very good connection among these units and the primary health care services. Our data were obtained from a homeless population living in a temporary residence and, thereby, they could not be representative of the dermatoses that could be found in the street homeless population, where poor hygiene and eating habits may lead to a higher prevalence and severity of skin diseases.

African tick bite fever is caused by the intracellular bacteria Rickettsia africae. This bacterium is transmitted through the bite of the Amblyomma tick, which carries a high rate of R. africae infection. African tick bite fever is the second most frequent cause of fever in travelers returning from sub-Saharan Africa.We present the case of a 58-year-old man, returning from South Africa, with a three-day history of fever, generalized headache and cervical myalgia. On physical examination multiple inoculation eschars and tender inguinal lymph nodes were documented.Histological examination of a skin lesion was compatible with spotted fever and the diagnosis of R. africae infection was confirmed through polymerase chain reaction analysis.The global increase in international tourism, particularly to remote areas, predisposes to tick bites. In febrile tourists returning from endemic areas and after a thorough clinical examination, the diagnosis of African tick bite fever should be born in mind.

At present, treating mycosis of the nail apparatus still remains a challenge. The infectious focus is entrapped on a specific anatomic structure where permanent resolution is sometimes unattainable, which means that onychomycosis often becomes a chronic condition that persists in an active state in the range of several years. The priority in recent developments of onychomycosis’ pharmacotherapy lies on topical monotherapies for use in patients who cannot take oral medication or prefer a topical drug and, as an additional advantage, to combine them with oral drugs and/or medical devices to expand the current treatment possibilities. This review encompasses therapeutic options for onychomycosis in the status quo. Two novel topical drugs, efinaconazole and tavaborole, received approval from the competent regulatory agency, the Food and Drug Administration (FDA), in 2014.

Syphilis is an old disease and a major public health concern, which is re-emerging in the western world. Atypical syphi- litic presentations can be challenging to diagnose. We present a 23-year-old, HIV-positive man who has sex with men who presented with a 2-week history of an asymptomatic lesion on the glans. Previous topical and systemic treatments proved unsuccessful. Physical examination demonstrated a slightly indurated, ill-defined erythematous plaque over most of the glans. Enlarged, non-tender, bilateral inguinal lymph nodes were palpable. Serological tests revealed a fourfold increase in the VDRL titre (1:8, previously 1:2). A diagnosis of syphilitic balanitis of Follmann was made and complete resolution was achieved with an intramuscular single dose of benzathine penicillin 2.4 MU. Syphilitic balanitis of Follmann represents an uncommon manifestation of primary syphilis, with less than 100 cases reported. Untrea- ted, it will resolve spontaneously, but the patient will remain highly infectious and at-risk for long-term morbidity. In an era in which the number of syphilis cases is increasing sharply both in Western Europe and the United States, all physicians should be aware for the typical and atypical early syphilitic manifestations as they represent opportunities of paramount importance for treatment and epide- mic control.

Introduction: Diagnostic uncertainty is an inseparable component of medical practice. The dichotomous classification of melanocytic lesions as benign or malignant has been replaced in recent years by a more flexible approach in which diagnostic uncertainty is recognized and accepted. Methods: In order to characterize the population of melanocytic proliferations of uncertain malignant potential diagnosed at our center between 2007 and 2017, histopathological reports of melanocytic lesions classified, in this period, as either dysplastic or malignant were analyzed. Results: Twenty-three lesions (4.3%) with borderline histopathological features or uncertain malignant potential were identified. The mean patient age was 34.8 years. Sixteen lesions (69.6%) were observed by a second pathologist. The most frequently performed treatment was wide excision. A sentinel lymph node biopsy was performed on 2 patients, both being negative. The median follow-up time was 22 months, and there was no recurrence of any treated lesion. Discussion: The controversy of the subject extends from the nature and classification of these lesions to their treatment. In this work we perform a statistical review of the population of melanocytic proliferations of uncertain malignant potential diagnosed in our department.

Introduction. Occupational Allergic Contact Dermatitis is a very common occupational disease and epoxy resins are among its main causes. The aim of this study was to characterize patients with positive patch test reactions to epoxy resin detected in the Coimbra Hospital and University Center between 2012 and 2018 and compare with the results of patients patch tested between 1999 and 2008 at the same Institution. Method and Materials.  Within aretrospective analysis of the files of patients with positive patch test reactions (1+ or more intense) to epoxy resin of bisfenol A tested at 1% pet. within the Baseline Series between 2012 and 2018, we characterized demographic and clinical data of reactive patients, evaluated the relevance of the reaction, sources of exposure to epoxy resin with particular attention to occupational exposures, other positive reactions and the impact of the results of the tests in the work conditions of these patients. Lastly, we compared these results with a previous study performed in the same Hospital between 1999 and 2008. Results. Among 2363 patch tested patients during the study period we found 23 patients (0.97%), 17 males and 6 females, who developed contact allergy to epoxy resins. In 22 cases we identified a relevant occupational exposure: 9 from construction industry; 9 workers from wind-mill turbines factory for Eolic energy; 2 from fiberglass factories; 1 from a chemical factory and 1 from a Wastewater Treatment Plant. In 1 patient (a teacher) no relevance was found. Of these 22 workers, 9 (39.1%) had both hand and airborne lesions, while 8 (34.8%) had lesions exclusively on the hands and 5 (21.7%) had predominately airborne dermatitis. Four of the 23 (17.4%) reacted exclusively to the epoxy resin, and 11 of 18 (61.1%) also reacted to 0.25% hexanediol diglycidyl ether. Avoidance resulted in a significant improvement of symptoms. Compared to the previous period (1999-2008), there are no significative changes apart from a slight increase in the frequency of the allergic reactions to epoxy resins and its main source of exposure. Conclusions. The prevalence of allergic contact dermatitis to epoxy resin has slightly increased in this Portuguese Center mostly due to workers from wind-mill turbines factory for Eolic energy, a recent industry implanted in this region. This allergen still causes almost exclusively occupational dermatitis, either hand, airborne, or both.

.

Introduction: Our objective was to briefly review the literature on the hypochromic variant of mycosis fungoides and highlight common differential diagnoses. Methods: This article consists of a literature review, and the search for references was performed in the Virtual Health Library (VHL) in Portuguese, English and Spanish, with a total of 47 references retrieved. Results: The hypochromic variant of mycosis fungoides is a rare form of this chronic cutaneous T-cell lymphoma, whose clinical presentation is diversified, giving a challenging and late diagnosis to the disease. As the clinical aspects are similar to common dermatoses such as leprosy and pityriasis alba, this hypochromic variant of mycosis fungoides is underdiagnosed or its diagnosis is delayed. Conclusion: The importance of conducting a detailed anamnesis and physical examination at medical appointments is highlighted for the correct diagnosis of unusual diseases, such as the one described, and to enable primary care to detect common cases ac- curately, referring the others to the dermatologist.

Leprosy is an infectious disease whose causative agent are the bacillus Mycobacterium leprae and Mycobacterium lepromatosis. It preferably affects the skin and peripheral nerves. If left undiagnosed and not treated early, it can cause severe deformation and disability. Paradoxically, as treatment became curative, many specialist centers closed, which led to a reduced knowledge of the disease. With the increasing immigration to Europe of people from countries with high prevalence of leprosy, new cases have appeared in European countries namely in Portugal. A strong stigma based on the fear of contagion contributes to the prolonged suffering and delays in diagnosis and treatment of these patients. We make a brief review of this old disease from the ancient times to the present day.

Cutaneous lupus erythematosus (CLE) includes a broad range of dermatologic manifestations, which may or may not be associated with systemic manifestations. Specific CLE - defined by the presence of an interface dermatitis on histopathological evaluation - is divided into several sub-types, namely acute CLE (ACLE), subacute CLE (SCLE) and chronic CLE (CCLE). CCLE includes discoid lupus erythematosus (DLE), as well as other rarer forms such as LE profundus (LEP). Nonspecific skin findings, such as livedo reticularis or purpura are more frequently seen in patients with systemic disease. Diagnosis requires classification of the subtype, through a combination of physical examination, laboratory studies, histology and sometimes direct immunofluorescence, at the same time ensuring to exclude systemic disease. Regarding the treatment of CLE, antimalarials and topical steroids continue to be the standard of care; however, immunosuppressants, thalidomide analogs and monoclonal antibodies are possible systemic therapies for recalcitrant disease. Patient education on proper sun protection and avoidance of triggers is crucial. This paper reviews the clinical manifestations of CLE, as well as the treatment.

Introduction: Clinical characteristics of frontal fibrosing alopecia (FFA) have been studied since its description in 1994 in Europe, North America and Australia, and the present study is the largest on FFA features in Latin America. Methods: This study, through questionnaire and medical records, describes characteristics of a Brazilian population of 59 patients with FFA, concerning clinical forms, individual features and use of cosmetic products. Results: Mean patients’ age was 58.4 years (range 35-84y). Duration of disease varied from six months to 20y (median 5y). Most women were postmenopausal (83.1%) and non-smokers (83.1%). Five percent had at least one associated autoimmune disease, most commonly hypothyroidism (13.6%). Six of 40 patients (15%) had lichen planus pigmentosus and ten had facial papules (25%). Eyebrow alopecia occurred in 50 (84.7%), and body hair loss in 47 (79.7%). Facial papules were more prevalent in premenopausal women. Conclusion: Studying FFA epide- miology may help understanding the pathophysiology of this epidemic disease and this study highlights similarities and differences to previously published studies in FFA, such as greater frequency in postmenopausal women, association with hypothyroidism and facial irritation with cosmetic products.

.

.

Sporotrichosis is the most common subcutaneous mycotic infection in Latin America. It is caused by Sporothrix schenkii. The most common presentation is the cutaneous-lymphatic form, which begins as papules that progress to ulcers along the lymphatic chain to the regional lymph node. Mucosal involvement is uncommon, and the more typical presentation is a granuloma- tous conjunctivitis associated with regional lymphadenopathy. Systemic dissemination to other organs is rare and occurs mostly in immunocompromised patients. Sporotrichosis can be associated with the occupational activity of workers in rural areas (agriculture, forest) or those dealing with animals like cats and armadillos. Currently urban outbreaks have been associated with the scratching and/or biting of infected cats. The authors report a case of a disseminated cutaneous sporotrichosis associated with eye damage in an immunocompetent patient, having the cat as the source of infection.

Melanocytic lesions and other skin tumors represent one of the most frequent reasons for pediatric dermatology consultation. Although often benign, some of them may simulate melanoma, which can be a source of anxiety for parents and clinicians. Dermoscopy is a non-invasive and painless technique that increases the diagnostic accuracy for skin tumours, while avoiding unnecessary skin biopsies. In part I of this article, we highlight the importance of dermoscopy for the diagnosis of skin tumors in pediatric patients.