Acute ulcerative lesions in HIV seropositive patient
1
INFECTION—BACTERIAL AND PARASITIC P6833 Acute ulcerative lesions in HIV seropositive patient Fred Bernardes Filho, MD, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Andreia Oliveira Alves, Universidade Metropolitana de Santos (UNIMES), Santos, Brazil; Fernanda de Figueiredo Bongiovani, Universidade de Ribeir~ ao Preto (UNAERP), Ribeir~ ao Preto, Brazil; Jos e Augusto da Costa Nery, PhD, MD, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Maria Vict oria Quaresma, MD, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Renata Pinto Fernandes Timb o, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Yamileth Cruz Ararat, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil Background: In HIV-infected patients, the syphilis coinfection is common and both diseases can mutually affect each other, resulting in alteration of serological responses or even a more severe clinical manifestation. Those patients have an increased chance of manifesting a more malign disease course, more constitutional symptoms and a larger number of infected organs. Observing that, the immunologic system dysfunction in AIDS is a possible explanation for the increased case numbers in this population. The infection has now found a new way; instead of spontaneous cure, the syphilis immunodepressed patients evolve more clinical diseases. Case report: A 33-year-old man, single, born in Rio de Janeiro, came to the service for diffused body lesions, especially in the upper body, associated to fever and bad general state. He has had multiple sexual partners and a history of 6-year-old HIV infection in use of antiretroviral therapy seven months ago, indicated by immunodeficiency. Physical examination demonstrated erythematous papular plaques with central ulcerated surface, covered with thick hemorrhagic crusts in the upper body, upper limbs, region neck, chin and micropoliadenomagalia widespread. Hypotheses have been suggested such as cutaneous herpes, cytomegalovirus cutaneous atypical mycobacteriosis, pyoderma gangrenosum, and syphilis. Exams: VDRL titer to 1/128 and FTA-ABS IgM reactive. A diagnosis was established with early malignant syphilis. Therapy was started with 3 doses of benzathine penicillin 2,400,000 IU with an interval of 7 days. VDRL was performed with a negative result. When the patient returned 30 days after the completion of the treatment, he presented cleared cutaneous lesions, being accom- panied by dermatology outpatient health. According to our industry’s protocol, the patient will have clinical reevaluation every 3 months and VDRL for a period of 2 years. Discussion: This case reforces that, for HIV seropositive patients presenting acute ulcerated lesions, syphilis suspicion and investigation must be mandatory. As coinfection in this scenario can lead to premature stages of invasive deceases, we must be aware of it. Our patient presented early malignant syphilis, secondary syphilis, although we opted for a 7,200,000 IU penicillin benzatine dose treatment for the patient’s safety. There is a necessity for more studies, demonstrating the efficacy of this drug according to the phases of syphilis coinfection with HIV. Commercial support: None identified. P7044 Clinical exuberance of Hansen disease: Case report Delky Johanna Villarreal Villarreal, MD, Instituto de Dermatologia Professor Rubem David Azulay, Rio De Janeiro, Brazil; Aline Tanus Luz, MD, Instituto de Dermatologia Professor Rubem David Azulay, Rio De Janeiro, Brazil; Alissa Elen Formiga Moura, Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro, Brazil; Camila Caberlon Cruz Oliveira, MD, Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro, Brazil; Lizandra Fujita de Paula Pessoa, Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro, Brazil; Maria Vit oria Quaresma, MD, Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro, Brazil; Natasha Sim~ oes Montenegro, Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro, Brazil Background: Hansen disease is a contagious disease caused by Mycobacterium leprae which affects preferably skin and peripheral nerves. In Brazil in 2011, 34,000 new cases were registered and 45% of them were multibacillary form. Its classification is defined by clinical forms (the ‘‘multibacillary’’ Virchowiana Hansen and the ‘‘paucibacillary’’ tuberculoid Hansen) as well as other intermediate forms with hybrid characteristics. Individuals with some type of immunosuppression have the Virchowiana form of the disease, which is characterized by extensive skin and peripheral nerves involvement. This report shows a delay in diagnosis and treatment of disease. Case report: Male, black, age 75 years, from RJ (Brazil) relates paresthesia, anesthesia and edema of hands and feet, xerosis of skin which started 2 years ago. Dermatologic examination: Aspect malnourished, dry skin, On the face: Madarosis and atrichia bilateral, erythematous violaceous and infiltrated plaques on the forehead, jaw region, pavilions and bilateral ears lobules, erythematous violaceous lobulated nodule of 1.5 cm in diameter on the left side of the nose. On the upper limbs: Erythematous violaceous nodules, thickening and hardening of the ulnar nerves, swelling of the hands (3+/4+), flexion of the proximal phalanx of the 5th fingers, exulcerated lesions on the dorsum of the hands. On the lower limbs: Thickening and hardening of the popliteal nerves, swollen feet (3+/4+) with changes in temperature and pain sensitivity in boots and gloves, hammer toes, plantar keratosis with some areas exulcerations plantar pressure, bone resorption the second and third toes of the right foot. Smear-positive. Discussion: The diagnosis of Hansen disease is primaly clinical, epidemiologic, supplemented if possible with bacteriologic and histopathologic examination. The peripheral nerves and skin manifestations of the disease present a singular clinical picture that is easily recognized. However, ignorance about leprosy is common both in the general population and health personnel, reason why it continues to be a public health problem in several countries. This report illustrates as Hansen disease continues to be endemic in Brazil because of late diagnosis. Commercial support: None identified. P6799 Clinical management with endovenous corticotherapy in patients with leprosy reactions Fred Bernardes Filho, MD, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Andreia Oliveira Alves, Universidade Metropolitana de Santos (UNIMES), Santos, Brazil; Gisele Reis Cunha Silva, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Jos e Augusto da Costa Nery, PhD, MD, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Maria Vict oria Quaresma, MD, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Ystannyslau Bernardes da Silva, MD, Hospital Benefic^ encia Portuguesa de Ribeir~ ao Preto, Ribeir~ ao Preto, Brazil Background: The reactional states are considered either acute or subacute episodes characterized by cutaneous or systemic onsets because of changes in immunologic state. Early detection and the commence of antiinflammatory medication consti- tutes the key to therapeutics whose target is to avoid neural damage. The treatment of reverse reaction or leprosy reaction type 1 aims to suppress the cellular immunologic response and demands immediate and adequate intervention because of the risks of systemic damages. Clinically, they modify the reverse reactions in several ways: by reducing both the cutaneous and intraneural edema leading to a fast recovery in the symptomatology. Case report: Male patient, 65 years old, married, born in Rio de Janeiro was moved from the basic health unit to hospitalization for presenting a clinical condition of leprosy reactions type 1 without clinical response to oral therapy. The patient started tuberculoid leprosy treatment 5 months ago with paucibacillary polyche- motherapy with prescription of 6 dosages. It is in his medical record that in the first 2 months the patient took the medication irregularly and, for this reason, he is forced to keep the treatment. For the past 10 days, based on the fact his condition was more acute, his preexisting lesions have worsened and he has experienced the onset of new lesions. Even after starting oral prednisone, the patient has not presented better conditions despite the fact his prescription is 80 mg/day. Through ectoscopy, it was observed the presence of several underlying erythematous patches throughout the tegument, edema and scaling of some lesions. As the reverse reaction was very adverse, the oral corticoid therapy was replaced by endovenous procedures being prescribed 1g/day of methylprednisolone for 3 consecutive days. The patient quickly improved his condition with intravenous corticoid therapy. Discussion: The objective of the treatment of the reverse reaction is to reduce inflammatory reaction, especially neural. We emphasize that at first multidrug therapy must be continued during reactional episode. Endovenous methylprednis- olone or pulse therapy in indicated with the following dosages; 1g of endovenous methylprednisolone with a single dosage for three consecutive days and then 1g a week for four consecutive weeks. Between pulses, 0.5 mg/kg/day of prednisone with progressive reduction of the dosage keeping the same extreme precautions for the chronic use of corticoids. Commercial support: None identified. P7071 Cutaneous larva migrans: An imported case Carmen Martinez Peinado, Dermatology Department, Almeria, Spain; Francisca Simon, Dermatology Department, Almeria, Spain; Josefa Orero, Dermatology Department, Almeria, Spain; Mercedes Alcalde, Dermatology Department, Almeria, Spain; Paloma Nogueras, Dermatology Department, Granada, Spain; Pilar Gomez, Dermatology Department, Almeria, Spain Background: Cutaneous larva migrans (CLM), or creeping eruption of the skin, is caused by the migration of animal hookworm larvae in the human skin. Hookworms of dogs and cats, such as Ancylostoma caninum and A braziliense, are the usual causative agents. The typical clinical manifestation of this skin disease is an itchy, erythematous, linear or serpiginous, dermatitis tract. In most cases, the feet, buttocks and thighs represent the main anatomic site affected by CLM, but any part of the body in contact with infested soil or sand can be involved. Topical or oral thiabendazole, oral albendazole or a single-dose of ivermectin are effective treatment options. We describe a case in a Spanish patient, after a trip to Jamaica. Case report: A 33-year-old woman from Spain presented with a 2-week history of skin lesions on her legs and abdomen. The patient was VHC+. The lesions were intensely pruritic and red. She had returned from a trip to Jamaica 1 week before the onset of the lesions. On examination, she presentes multiple raised and erythem- atous serpiginous tracts. The findings were clinically consistent with cutaneous larva migrans. Complete blood count was normal. A skin biopsy showed nematode larvae close to hairs with paired spicules in the cuticle, which are typical of the ancylostoma. Treatment with albendazole 400 mg/12 hours for 4 days results in a complete recovery. Discussion: The diagnosis of cutaneous larva migrans is based on exposure history and morphology of skin lesions. The parasite is not always showed in skin biopsy. Humans are accidentally infected by the larvae from contaminated soil. The larva is unable to penetrate the dermis and remains in the epidermis and hair follicles, causing red swollen and serpiginous tracks. Scratching may cause extensive excoriations and subsequent bacterial superinfection of the lesions. The mainstay for prevention is the use of proper footwear when traveling to endemic areas. The disease causes intense pruritus and is associated with important morbidity, besides it is the most frequent tropical dermatosis. Commercial support: None identified. AB116 JAM ACAD DERMATOL APRIL 2013
Transcript of Acute ulcerative lesions in HIV seropositive patient
INFECTION—BACTERIAL AND PARASITIC
P6833Acute ulcerative lesions in HIV seropositive patient
Fred Bernardes Filho, MD, Instituto de Dermatologia Prof. Rubem David Azulay daSanta Casa da Miseric�ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro,Brazil; Andreia Oliveira Alves, Universidade Metropolitana de Santos (UNIMES),Santos, Brazil; Fernanda de Figueiredo Bongiovani, Universidade de Ribeir~ao Preto(UNAERP), Ribeir~ao Preto, Brazil; Jos�e Augusto da Costa Nery, PhD, MD, Institutode Dermatologia Prof. RubemDavid Azulay da Santa Casa da Miseric�ordia do Rio deJaneiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Maria Vict�oria Quaresma, MD,Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric�ordiado Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Renata Pinto FernandesTimb�o, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa daMiseric�ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; YamilethCruz Ararat, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa daMiseric�ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil
Background: In HIV-infected patients, the syphilis coinfection is common and bothdiseases can mutually affect each other, resulting in alteration of serologicalresponses or even a more severe clinical manifestation. Those patients have anincreased chance of manifesting a more malign disease course, more constitutionalsymptoms and a larger number of infected organs. Observing that, the immunologicsystem dysfunction in AIDS is a possible explanation for the increased case numbersin this population. The infection has now found a new way; instead of spontaneouscure, the syphilis immunodepressed patients evolve more clinical diseases.
Case report: A 33-year-old man, single, born in Rio de Janeiro, came to the service fordiffused body lesions, especially in the upper body, associated to fever and bad generalstate.Hehashadmultiple sexualpartners andahistoryof6-year-oldHIV infection inuseof antiretroviral therapy seven months ago, indicated by immunodeficiency. Physicalexamination demonstrated erythematous papular plaques with central ulceratedsurface, coveredwith thick hemorrhagic crusts in the upper body, upper limbs, regionneck, chin and micropoliadenomagalia widespread. Hypotheses have been suggestedsuch as cutaneous herpes, cytomegalovirus cutaneous atypical mycobacteriosis,pyoderma gangrenosum, and syphilis. Exams: VDRL titer to 1/128 and FTA-ABS IgMreactive.A diagnosiswas establishedwith earlymalignant syphilis. Therapywas startedwith3 doses of benzathinepenicillin 2,400,000 IUwith an interval of 7 days. VDRLwasperformed with a negative result. When the patient returned 30 days after thecompletion of the treatment, he presented cleared cutaneous lesions, being accom-panied by dermatology outpatient health. According to our industry’s protocol, thepatientwill have clinical reevaluation every 3months and VDRL for a period of 2 years.
Discussion: This case reforces that, for HIV seropositive patients presenting acuteulcerated lesions, syphilis suspicion and investigation must be mandatory. Ascoinfection in this scenario can lead to premature stages of invasive deceases, wemust be aware of it. Our patient presented early malignant syphilis, secondarysyphilis, although we opted for a 7,200,000 IU penicillin benzatine dose treatmentfor the patient’s safety. There is a necessity for more studies, demonstrating theefficacy of this drug according to the phases of syphilis coinfection with HIV.
AB116
cial support: None identified.
CommerP7044Clinical exuberance of Hansen disease: Case report
Delky JohannaVillarrealVillarreal,MD, InstitutodeDermatologiaProfessorRubemDavidAzulay, Rio De Janeiro, Brazil; Aline Tanus Luz, MD, Instituto de Dermatologia ProfessorRubem David Azulay, Rio De Janeiro, Brazil; Alissa Elen Formiga Moura, Instituto deDermatologiaProfessorRubemDavidAzulay,Riode Janeiro,Brazil;CamilaCaberlonCruzOliveira, MD, Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro,Brazil; Lizandra Fujita de Paula Pessoa, Instituto de Dermatologia Professor RubemDavidAzulay, Rio de Janeiro, Brazil; Maria Vit�oria Quaresma, MD, Instituto de DermatologiaProfessor Rubem David Azulay, Rio de Janeiro, Brazil; Natasha Sim~oes Montenegro,Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro, Brazil
Background: Hansen disease is a contagious disease caused byMycobacterium lepraewhichaffectspreferably skin andperipheralnerves. InBrazil in2011,34,000newcaseswere registered and 45% of themwere multibacillary form. Its classification is definedby clinical forms (the ‘‘multibacillary’’ Virchowiana Hansen and the ‘‘paucibacillary’’tuberculoid Hansen) as well as other intermediate forms with hybrid characteristics.Individuals with some type of immunosuppression have the Virchowiana form of thedisease, which is characterized by extensive skin and peripheral nerves involvement.This report shows a delay in diagnosis and treatment of disease.
Case report: Male, black, age 75 years, from RJ (Brazil) relates paresthesia, anesthesiaand edema of hands and feet, xerosis of skin which started 2 years ago. Dermatologicexamination: Aspect malnourished, dry skin, On the face: Madarosis and atrichiabilateral, erythematous violaceous and infiltrated plaques on the forehead, jaw region,pavilions and bilateral ears lobules, erythematous violaceous lobulated nodule of1.5 cm in diameter on the left side of the nose. On the upper limbs: Erythematousviolaceousnodules, thickeningandhardeningof theulnar nerves, swellingof thehands(3+/4+), flexion of the proximal phalanx of the 5th fingers, exulcerated lesions on thedorsum of the hands. On the lower limbs: Thickening and hardening of the poplitealnerves, swollen feet (3+/4+) with changes in temperature and pain sensitivity in bootsand gloves, hammer toes, plantar keratosis with some areas exulcerations plantarpressure, bone resorption the second and third toes of the right foot. Smear-positive.
Discussion: The diagnosis of Hansen disease is primaly clinical, epidemiologic,supplemented if possible with bacteriologic and histopathologic examination. Theperipheral nerves and skin manifestations of the disease present a singular clinicalpicture that is easily recognized. However, ignorance about leprosy is common bothin the general population and health personnel, reason why it continues to be apublic health problem in several countries. This report illustrates as Hansen diseasecontinues to be endemic in Brazil because of late diagnosis.
cial support: None identified.
CommerJ AM ACAD DERMATOL
P6799Clinical management with endovenous corticotherapy in patients withleprosy reactions
Fred Bernardes Filho, MD, Instituto de Dermatologia Prof. Rubem David Azulayda Santa Casa da Miseric�ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro,Brazil; Andreia Oliveira Alves, Universidade Metropolitana de Santos (UNIMES),Santos, Brazil; Gisele Reis Cunha Silva, Instituto de Dermatologia Prof. RubemDavid Azulay da Santa Casa da Miseric�ordia do Rio de Janeiro (IDPRDA/SCMRJ),Rio de Janeiro, Brazil; Jos�e Augusto da Costa Nery, PhD, MD, Instituto deDermatologia Prof. Rubem David Azulay da Santa Casa da Miseric�ordia do Rio deJaneiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Maria Vict�oria Quaresma, MD,Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa daMiseric�ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil;Ystannyslau Bernardes da Silva, MD, Hospital Beneficencia Portuguesa deRibeir~ao Preto, Ribeir~ao Preto, Brazil
Background: The reactional states are considered either acute or subacute episodescharacterized by cutaneous or systemic onsets because of changes in immunologicstate. Early detection and the commence of antiinflammatory medication consti-tutes the key to therapeutics whose target is to avoid neural damage. The treatmentof reverse reaction or leprosy reaction type 1 aims to suppress the cellularimmunologic response and demands immediate and adequate intervention becauseof the risks of systemic damages. Clinically, they modify the reverse reactions inseveral ways: by reducing both the cutaneous and intraneural edema leading to a fastrecovery in the symptomatology.
Case report: Male patient, 65 years old, married, born in Rio de Janeiro was movedfrom the basic health unit to hospitalization for presenting a clinical condition ofleprosy reactions type 1 without clinical response to oral therapy. The patientstarted tuberculoid leprosy treatment 5 months ago with paucibacillary polyche-motherapywith prescription of 6 dosages. It is in hismedical record that in the first 2months the patient took the medication irregularly and, for this reason, he is forcedto keep the treatment. For the past 10 days, based on the fact his condition was moreacute, his preexisting lesions have worsened and he has experienced the onset ofnew lesions. Even after starting oral prednisone, the patient has not presented betterconditions despite the fact his prescription is 80 mg/day. Through ectoscopy, it wasobserved the presence of several underlying erythematous patches throughout thetegument, edema and scaling of some lesions. As the reverse reaction was veryadverse, the oral corticoid therapy was replaced by endovenous procedures beingprescribed 1g/day of methylprednisolone for 3 consecutive days. The patientquickly improved his condition with intravenous corticoid therapy.
Discussion: The objective of the treatment of the reverse reaction is to reduceinflammatory reaction, especially neural. We emphasize that at first multidrugtherapy must be continued during reactional episode. Endovenous methylprednis-olone or pulse therapy in indicated with the following dosages; 1g of endovenousmethylprednisolone with a single dosage for three consecutive days and then 1g aweek for four consecutive weeks. Between pulses, 0.5 mg/kg/day of prednisonewith progressive reduction of the dosage keeping the same extreme precautions forthe chronic use of corticoids.
cial support: None identified.
CommerP7071Cutaneous larva migrans: An imported case
Carmen Martinez Peinado, Dermatology Department, Almeria, Spain; FranciscaSimon, Dermatology Department, Almeria, Spain; Josefa Orero, DermatologyDepartment, Almeria, Spain; Mercedes Alcalde, Dermatology Department,Almeria, Spain; Paloma Nogueras, Dermatology Department, Granada, Spain;Pilar Gomez, Dermatology Department, Almeria, Spain
Background: Cutaneous larva migrans (CLM), or creeping eruption of the skin, iscaused by the migration of animal hookworm larvae in the human skin. Hookwormsof dogs and cats, such as Ancylostoma caninum and A braziliense, are the usualcausative agents. The typical clinical manifestation of this skin disease is an itchy,erythematous, linear or serpiginous, dermatitis tract. In most cases, the feet,buttocks and thighs represent the main anatomic site affected by CLM, but any partof the body in contact with infested soil or sand can be involved. Topical or oralthiabendazole, oral albendazole or a single-dose of ivermectin are effectivetreatment options. We describe a case in a Spanish patient, after a trip to Jamaica.
Case report: A 33-year-old woman from Spain presented with a 2-week history ofskin lesions on her legs and abdomen. The patient was VHC+. The lesions wereintensely pruritic and red. She had returned from a trip to Jamaica 1 week before theonset of the lesions. On examination, she presentes multiple raised and erythem-atous serpiginous tracts. The findings were clinically consistent with cutaneouslarva migrans. Complete blood count was normal. A skin biopsy showed nematodelarvae close to hairs with paired spicules in the cuticle, which are typical of theancylostoma. Treatment with albendazole 400 mg/12 hours for 4 days results in acomplete recovery.
Discussion: The diagnosis of cutaneous larva migrans is based on exposure historyand morphology of skin lesions. The parasite is not always showed in skin biopsy.Humans are accidentally infected by the larvae from contaminated soil. The larva isunable to penetrate the dermis and remains in the epidermis and hair follicles,causing red swollen and serpiginous tracks. Scratching may cause extensiveexcoriations and subsequent bacterial superinfection of the lesions. The mainstayfor prevention is the use of proper footwear when traveling to endemic areas. Thedisease causes intense pruritus and is associated with important morbidity, besides itis the most frequent tropical dermatosis.
cial support: None identified.
CommerAPRIL 2013
