Single-stage nasal reconstruction with the islanded forehead flap.

BACKGROUND AND PURPOSES: Multi-staged forehead flaps are a well-recognised reconstructive workhorse for subtotal and total nasal defects. It carries the disadvantage of repeated trips to theatre for revisional surgery, which is not suited to all patient cohorts. The single-stage islanded forehead flap eliminates this need. We detail our indications and outcomes of using this flap to highlight the maintained versatility of the technique without significant compromise on reconstructive and patient outcome. SUBJECTS STUDIED AND METHODS: A prospective surgical database was collated where patients were categorised as partial or total reconstruction. We detail surgical technique and review of rationale of patient selection. Patient demographics, perioperative data and follow-up course were recorded. MAIN FINDINGS: A total of 22 patients were recorded from both the U.K. and Ethiopia via working with the charity Facing Africa. Defects occurred from a mixture of trauma, Noma and cancer resections. Thirteen were total nasal reconstructions and nine partial. The mean follow-up period was 2.25 years. We experienced two major complications which required minor revision in the theatre and two minor complications, all resolved satisfactorily. CONCLUSIONS: We demonstrate good outcomes and safety of the procedure in this first report of a varied cohort of nasal reconstructions in a heterogenous cohort of patients. We advocate the use of this flap in the multi-morbid patient where recovery can be expedited or those who have limitations from economical restraints.

Application of laser for treatment of cutaneous leishmaniasis: a review of literature.

Cutaneous leishmaniasis (CL) is a major health problem in developing countries with high economic and health impact. Despite suggested treatment for CL, there is still no definite therapy for this infection, and many of these treatments are associated with serious local and systemic side effects. In the current paper, use of different laser types including continuous and fractional CO2, argon, PDL, erbium glass, and Nd:YAG have been reviewed. Based on our review, given the high reported efficacy and low side-effect profile, use of laser can be considered as a good alternative to standard treatment of cutaneous leishmaniasis (CL). Performing more studies using different types of lasers is recommended to evaluate the efficacy of this method for treatment of CL.

[Axillary hidrosadenitis due to Leishmania: Case report and literature review]. / Hidrosadenitis axilar por Leishmania: presentación de un caso y revisión de la bibliografía.

BACKGROUND: Hidradenitis is a disorder where abscesses appear after the infection of the apocrine sweat glands. It is located normally in the axillae, groin, perineal region, and the scalp. CLINICAL CASE: A 37 year old male was referred by his GP to the General Surgery Department with axillary hidradenitis which had evolved over the years. The physical examination shows signs of hidradenitis in both axillae, with a noticeable suppurative hidradenitis in the right armpit. En bloc extirpation was performed to remove the whole affected area. The pathological examination revealed a cutaneous leishmaniasis. Subsequently, fucidin was administered topically, as well as local infiltrations of one millilitre of Glucantime™. DISCUSSION: Hidradenitis normally appears in intertriginous areas and its manifestation is accompanied by recurrent subcutaneous nodules. The incidence rate in females is three times higher than in males. The isolated Hidradenitis caused by Leishmania is a rare condition presented only in endemic areas or in immunocompromised patients, such as HIV-infected patients. Clinical manifestations can be different and the diagnosis can be confirmed through haematoxylin-eosin. The main pattern displays a disorganised granuloma without necrosis. Systemic or topical treatment can be applied. Immunotherapy treatment is the most common. CONCLUSIONS: Hidradenitis caused by Leishmania in HIV-negative patients is a rare condition. Therefore it is important to perform a good histological diagnosis and to administer the right treatment.

Paronychia-like cutaneous leishmaniasis.

Chronic paronychia is an inflammatory recalcitrant disorder affecting the nail folds. We report one patient with paronychia revealing ungueal leishmaniasis. A 34-year-old man, resident in the north of Morocco, presented with a 6-month history of an inflamed proximal nail fold of the left thumb, resistant to antibiotics and anti-fungal treatments. En bloc excision of the proximal nail fold was done. The histopathological exam showed epithelioid granulomas with giant cells and the presence of leshmania amastigotes, leading to the diagnosis of ungueal leishmaniasis. Clinical aspects of cutaneous leishmaniasis can be very misleading. The paronychial form is rarely described. In endemic areas it is necessary for the physician to be aware of atypical skin presentations of leishmaniasis.

Non-healing old world cutaneous leishmaniasis caused by L. infantum in a patient from Spain.

BACKGROUND: The prevalence of Old World Cutaneous Leishmaniasis in the Mediterranean region is increasing and in Southern Europe often caused by Leishmania infantum. Spontaneous healing of cutaneous leishmaniasis is commonly observed, especially if caused by L. major, whereas L. infantum associated lesions have been reported with longer disease duration and decreased tendency for self-limitation, however, available information is sparse. CASE PRESENTATION: We report the case of an otherwise healthy woman from Southern Spain who presented with a seven years persistent, non-healing, painless, central ulcerated, nodular cutaneous lesion with a diameter of 2 cm of the forearm. Cutaneous leishmaniasis was diagnosed by smear and histology, showing large amounts of leishmania amastigotes in subepidermal histiocytes and extensive lymphocyte and plasma cell inflammation. L. infantum as the causative pathogen was confirmed by restriction fragment length polymorphism and microsatellite-PCR. Systemic or visceral involvement was excluded by negative leishmania serology and clinical presentation, relevant concomitant diseases or immunosuppression were excluded including quantification of immunoglobulin levels and lymphocyte phenotyping. Topical and systemic anti-infectious treatment options, often limited in terms of efficacy, tolerability and long lasting treatment duration, were considered. Treatment was successfully performed by surgical extraction in local anaesthesia only. CONCLUSION: To our knowledge this is the longest reported duration of a L. infantum associated cutaneous leishmaniasis indicating a potential long lasting natural evolution of the disease in an otherwise healthy and immunocompetent patient, however, high parasite density may have reflected a lack of a L. infantum specific immune response. Complete surgical extraction can be successfully performed as treatment.

Cutaneous leishmaniasis: cryosurgery using carbon dioxide slush in a resource-poor country.

Leishmaniasis is a widespread parasitic disease seen most often in children and young adults, although it may occur at any age. In Yemen, up until now, specific treatment for cutaneous leishmaniasis (CL) has been challenging. Available chemotherapy is expensive and replete with significant side effects. Standard cryosurgery with liquid nitrogen is prohibitively expensive and often unavailable. The objective of this paper is to highlight the importance of cryosurgery with carbon dioxide slush in the treatment of CL in an economically underdeveloped region as a cost-effective, simple, successful, and affordable option.

An unusual manifestation of a neglected disease.

We report on a 30-year-old man that was seen by dermatologist for a routine check of melanocytic nevi. During the examination he pointed out a lesion on his upper back, stating that he did not know how long it had been there. Excision was performed and the histopathologic examination showed a dense granulomatous infiltrate in the dermis without ulceration. It turned out to be cutaneous leishmaniasis, the incidence of which is increasing in our immediate vicinity, and therefore it is important to constantly keep it in mind during everyday work at the clinic.

Basal cell carcinoma in a full-thickness skin graft in the upper eyelid.

A 75-year-old woman presented with a nodular lesion on a skin graft in her left upper eyelid. The lesion had grown gradually over the previous 2 years. She had undergone multiple surgeries and full-thickness skin graft procedures 61 years previously, because of cutaneous leishmaniasis. The diagnosis of nodular basal cell carcinoma was made by means of an excisional biopsy of the lesion. During a follow-up period of 27 months, the tumor did not recur. Malignant tumors may rarely develop at the site of traumatic or surgical scar. To our knowledge, this is the first reported case of basal cell carcinoma arising in a skin graft in the eyelid.

Leishmaniasis of the lip : report of a case.

Leishmaniasis is a parasitic disease caused by a protozoan flagellate of the genus Leishmania. This parasite infects numerous mammal species including humans. It is transmitted through the infective bite of a sand fly called phlebotominae. Cutaneous Leishmaniasis is the most common form of Leishmaniasis. We present the case of a 47 years- old man who came to our Department of oral and maxillo-facial surgery, complaining about a painless lesion on his lower lip. After removal of the lesion and microscopic examination, the diagnosis of Leishmaniasis was made. This clinical case illustrates that the differential diagnosis of a nodular painless lesion of the lip must include rare diagnosis like a cutaneous Leishmaniasis, especially in patient from a geographic origin which represents an area at risk for Leishmaniasis.

Efficacy of CO(2) laser for treatment of anthroponotic cutaneous leishmaniasis, compared with combination of cryotherapy and intralesional meglumine antimoniate.

BACKGROUND: Cutaneous leishmaniasis (CL) is endemic in developing countries. Several types of treatments have been suggested, but none of them is completely effective and without side-effects. CO(2) laser has a specific thermolysis effect on infected tissues in CL. OBJECTIVES: To determine the efficacy and safety of CO(2) laser vs. combined cryotherapy and intralesional meglumine antimoniate (glucantime) in dry-type CL. METHODS: This is a prospective, randomized open trial study (Kerman, Iran) from November 2007 to August 2009. A total of 96 patients were randomly assigned to receive one session of CO(2) laser therapy and 95 patients on combined cryotherapy biweekly with intralesional meglumine antimoniate weekly until complete cure or up to 12 weeks, whichever is earlier. Clinical and laboratory cure, defined as complete re-epithelialization of 100%, complete flattening of induration and negative smear of lesions compared with baseline at weeks 2, 6, 12 and 16, and also at the time of complete cure (week 2, 6, 12 or 16). RESULTS: Of 191 participants, 80 patients with 95 lesions in group A and 80 patients with 95 lesions in group B completed the study. Complete cure was 93.7% (89/95 lesions) in group A and 78% (74/95 lesions) in group B. Complications were similar in the two groups and were limited to the ulcer sites. CONCLUSIONS: The CO(2) laser was more effective in treating dry-type cutaneous leishmaniasis than combined cryotherapy and intralesional glucantime and resulted in a shorter healing time (6 weeks vs. 12 weeks) with a single treatment session.

Reconstrução heminasal direita com rotação de retalho cutâneo bilobado: contribuição pessoal / Right heminasal reconstruction with bi-lobed skin flap rotation: personal approach

Deformidades adquiridas do nariz por trauma ou doença têm sido corrigidas mediante retalhos cutâneos em ilha, nasogenianos, frontais, tubulados, e ainda pelo uso de retalhos bilobados. O caso relatado, mediante modificação pessoal, ilustra este tipo de procedimento.

Acquired nasal deformity by trauma or sickness have been reconstructed by island skinflaps, nasal-labial, frontal, skin tube, and also with bi-lobed flap rotation. The present cases how a personal approach with the use of this bi-lobed flap.

Splenectomy does not interfere with immune response to Leishmania major infection in mice.

Spleen is one of the largest lymphoid organs in the body; it harbors immune cells including antigen presenting cells, B and T lymphocytes. It has an important role in humoral and cellular immune responses. Herein we investigated the role of spleen in the immune response to experimental Leishmania major infection. It is known that C57BL/6 mice are resistant to L. major infection whereas BALB/c mice are susceptible. Although splenectomy was associated with reduced serum levels of IFN-gamma, absence of the spleen did not change the profile of L. major infection in the resistant C57BL/6 and BALB/c susceptible mice. Both strains of mice maintained the same profile of cytokine production in regional lymph nodes after splenectomy and responded in the same way against the infection. Only splenectomized BALB/c mice had a reduction in IL-4 and IL-10 production by lymph node cells early in infection. Our data suggest that, in localized infections, regional lymph nodes may replace efficiently the immunological role of spleen in the cellular and humoral immune responses.

Diagnosing cutaneous leishmaniasis: the advantage of forward deployed histology in avoiding a surgical pitfall.

Military surgeons are often consulted for excisional debridement of skin lesions that fail to respond to medical therapy among soldiers who have been operating in areas of Afghanistan where cutaneous leishmaniasis is endemic. Wide surgical excision without knowledge of the primary etiology can lead to a surgical pitfall. Failure to properly treat cutaneous leishmaniasis, however, can lead to medical pitfalls of permanent disfigurement, deformity, and disability. Forward deployed surgeons should be supported by a laboratory that can confirm the presence of atypical organisms in biopsies of these lesions. With a x 100 microscope and Wright-Giemsa stains, a medical treatment facility is able to confirm cutaneous leishmaniasis, which allows for rapid transfer of soldiers for definitive antimicrobial therapy.

Carbon dioxide laser for the treatment of lupoid cutaneous leishmaniasis (LCL): a case series of 24 patients.

We report the use of a carbon dioxide laser to vaporize local cutaneous leishmaniasis. We used CO2 laser for the treatment of 24 patients with lupoid cutaneous leishmaniasis in Isfahan. We identified 24 patients with lupoid cutaneous leishmaniasis (LCL) for evaluation. All of the patients had clinical signs of LCL and had the lesion for more than 1 year. LCL diagnosis was confirmed by both direct smear and biopsy. The efficacy of laser was determined on the basis of cure and lack of relapse after 1 year. Treatment was performed using a CO2 laser (Lasersonic LS500 machine). The maximum power was 100 Watts and the pulse width was 0.5-5 seconds. There were 21 patients, 13 females and 8 males, who were treated and followed for 1 year. Mean duration of the lesions was 4.1+/- 3.9 years. The treatment was well tolerated and complications were minimal, and included pain, xerosis, and mild erythema. Of these patients, 19 were disease free (90.47 % efficacy based on clinic and laboratory). Only 2 patients were treatment failures (9.5 %). Our results indicate that CO2 laser radiation is highly effective for treatment of lupoid cutaneous leishmaniasis.

Treatment of cutaneous leishmaniasis with cryosurgery.

BACKGROUND: The management of cutaneous leishmaniasis with topical methods, if effective, can spare patients from long and costly inpatient treatments. METHODS: Seventeen patients with cutaneous leishmaniasis were treated with cryosurgery using liquid nitrogen as the cryogen. Two cycles of 10-30 s freezing time were used and repeated at 3-week intervals. RESULTS: All patients responded well to therapy with excellent cosmetic results and no relapse in any case. Side-effects were rare. CONCLUSIONS: Cutaneous leishmaniasis can be successfully treated with a simple protocol of cryosurgery with minor side-effects.