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.

Commer

P7044Clinical 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.

Commer

J 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.

Commer

P7071Cutaneous 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.

Commer

APRIL 2013