Pain and pruritus in cutaneous lupus: their association with dermatologic quality of life and disease activity.

OBJECTIVES: To evaluate the association of pain and pruritus with Dermatologic Quality of Life (QoL) and cutaneous disease activity in patients with 1) specific cutaneous lupus erythematosus (CLE) lesions, 2) non-specific CLE lesions and 3) both types of CLE lesions. METHODS: We evaluated 42 consecutive SLE patients with at least one active lesion attributed to lupus. Pain and pruritus were evaluated using a visual analogue scale, dermatologic QoL with the DLQI, clinical activity with the CLASI score and systemic activity with the SLEDAI-2K. RESULTS: The patients were predominantly females, mean age 34.2±11.2 years and median SLE duration of 7 years. Sixteen patients (38%) had specific lesions, 12 (28.5%) non-specific lesions and 14 patients (33%) both lesions. Patients with both lesions had the highest CLASI activity scores (median 17) (p<0.0001), all the cases of severe activity (p=0.002) and higher (worst) DLQI scores (median 11.5, p=0.04). The overall median pain score was 5 (0-9). Patients with non-specific or the combination of both CLE lesions had more pain (p<0.008). Pain correlated with the DLQI (τ=0.38, p=0.001) and the CLASI activity score (τ=0.47, p=0.002). Pain was more intense in vasculitis and bullous lesions followed by oral ulcers. Pruritus score did not differ among groups (median 6) and did not correlate with the DLQI or the CLASI activity score. CONCLUSIONS: We identified pain as a factor that correlated with dermatologic QoL and cutaneous activity. In this sense, this feature needs to be considered as part of the treatment targets in lupus.

Amicrobial pustulosis of the folds associated with autoimmune disorders: systemic lupus erythematosus case series and first report on the association with autoimmune hepatitis.

Amicrobial pustulosis of the folds (APF) associated with autoimmune disorders is an infrequent entity characterized by the recurrent appearance of follicular and nonfollicular sterile pustules in the context of autoimmune disease. Most reports on APF suggest systemic lupus erythematosus (SLE) as the major immunological associated disorder but the association with autoimmune hepatitis (AH) has not been previously documented. We describe the clinical and histological characteristics of 5 patients with APF: 4 with SLE and 1 with AH. As APF is an exclusion diagnosis, in order to establish an opportune diagnosis and treatment, physicians should be aware of patients with any autoimmune disease who develop a pustular dermatosis for which cultures and stains are negative. We propose the inclusion of anti-liver kidney microsome antibodies in the minor criteria for APF diagnosis.

[Dermatoses in patients with acute myeloid and lymphoid leukemia. Cohort follow-up in a tertiary care hospital]. / Dermatosis en pacientes con leucemia aguda mieloide y linfoide. Seguimiento de una cohorte en un hospital de tercer nivel.

INTRODUCTION: Cutaneous manifestations in patients with acute leukemia (AL) cover a broad spectrum, including those due to leukemia per se, to chemotherapy and other drugs and those inherent to hospital care. MATERIAL AND METHODS: This is a cohort study in a tertiary hospital setting where the development of dermatoses was followed for 2 years in 22 patients with the diagnosis of AL. RESULTS: During the study, all patients developed some type of dermatosis, mostly due to chemotherapy.

[Multicentric and localized tineas in immunocompromised patients]. / Tiñas multifocales y localizadas en pacientes inmunosuprimidos.

From the dermatological point of view, multifocal or multicentric tineas are widespread dermatophytic infections affecting two or more anatomical areas. In the immunosuppressed patient, these lesions are frequently atypical and the risk factors are not well established. The aims of this study were: to determine the risk factors associated to multicentric tinea in immunocompromised patients; to evaluate the immune response by trichophytin and candidin skin test, to determine the etiological agent and to quantify some serum interleukines. Thirty-six multicentric tinea and 37 localized tinea patients, both with immunocompromised factors, were included. By means of a questionnaire several risk factors were identified; the trichophytin and candidin skin test was evaluated after 48 hours. Mycological direct examination and culture were performed. The interleukins IL-2, IL-4, IL-10 and interferon gamma were quantified by ELISA. Statistical analysis was made by Chi-square, U Mann Whitney and logistic regression. In disseminated tinea patients a predominance of females (69%) versus localized tinea patients (30%) was observed. Prednisone, azathioprine and cyclophosphamide treatment was associated to multicentric tinea. Trichophytin was negative in all disseminated tinea patients and positive in only three localized tinea cases, candidin was positive in six and eight cases of multicentric and localized tinea respectively. Trichophyton rubrum was the most frequent etiological agent. No differences in interleukin concentrations were found. Female gender and some immunosuppressor treatments were associated with a high probability to develop multicentric tinea. In this study a defect in the cellular immune response was the possible explanation for the extensive reactions.

Warts, malnutrition, and sunshine.

Viral warts are common in poor rural settings but their relationship to malnutrition has not been studied. We sought to determine the prevalence of warts in children of two communities in Oaxaca, Mexico, and compared it with their nutritional status. Children from Santa Catarina Yahuio and Santiago Laxopa of the state of Oaxaca were examined. Localization, number, and type of verruca were noted. Date of birth, height, and weight were obtained to determine nutritional status. A total of 213 children (116 girls and 97 boys), 107 in Yahuio and 106 in Laxopa, were studied. Mean age was 10.24 years. Thirty children (14.1%) had warts and 80% (24/30) of these lived in Yahuio (p = 0.0002). Almost half were teenagers. Most lesions were on sun-exposed areas. First degree malnutrition was found in 24.5%; second degree in 23.6% and third degree in 14.2%. A higher frequency of warts than previously reported was found. Malnutrition was prevalent in both groups but did not correlate positively with verruca. Verruca were more frequent in females, adolescents, sun-exposed areas, and higher altitude. We believe that the higher altitude of Yahuio facilitates greater exposure to ultraviolet light-induced immune suppression.

Immunohistochemistry screening of sebaceous lesions for Muir-Torre syndrome in a 26-year period in a Mexican population.

Muir-Torre syndrome (MTS) is an autosomal dominant genodermatosis defined as the association of rare sebaceous gland skin tumors, keratoacanthomas, and a personal or familial history of malignant visceral tumors. Germline mutations in certain mismatch repair genes (MMR) have been identified in MTS families and their identification is a cornerstone for diagnosis of MTS. We reviewed our series of sebaceous neoplasms and performed immunohistochemistry (IHC) in order to screen for new MTS cases. Sebaceous neoplasms and visceral tumors from the same patient diagnosed between 1980-2006 were included. Immunohistochemistry to determine the presence or absence of MMR gene products in skin and visceral tumors was performed with mouse monoclonal antibodies anti-MSH2, anti-MSH6 and anti-MLH1. Six sebaceous neoplasms were identified in six females. Four patients presented a lack of expression of at least one of the MMR proteins in visceral and cutaneous neoplasms, thus warranting the diagnosis of MTS. Immunohistochemistry is a useful and accessible technique for the characterization of MMR gene expression in patients with sebaceous neoplasms.

Oral and Cutaneous Lymphomas other than Mycosis Fungoides and Sézary Syndrome in a Mexican Cohort: Recategorization and Evaluation of International Geographical Disparities.

BACKGROUND: Nonmycosis fungoides/Sézary syndrome (non-MF/SS) primary cutaneous lymphomas (PCL) are currently categorized under the 2005-World Health Organization/European Organization for Research and Treatment of Cancer (WHO-EORTC) classification for PCL. These differ in behavior from secondary cutaneous lymphomas (SCL) and to lymphomas limited to the oral cavity (primary oral lymphomas [POL]) both categorized under the 2016-WHO classification for lymphoid neoplasms. AIMS: This study aims to report the first series of non-MF/SS PCL, SCL, and POL in a Mexican cohort, examine the applicability of current classification systems and compare our findings with those from foreign cohorts. MATERIALS AND METHODS: Eighteen non-MF/SS PCL, four SCL, and two POL with available tissue for morphology and immunophenotypic assessment were reclassified according to the 2005-WHO/EORTC and 2016-WHO classifications. RESULTS: Non-MF/SS PCLs were primarily of T-cell origin (61%) where CD30+ lymphoproliferative disorders predominated, followed by Epstein-Barr virus-induced lymphomas, and peripheral T-cell lymphomas, not otherwise specified. Primary cutaneous B-cell lymphomas (BCL) were primarily of follicle center cell origin followed by postgerminal lymphomas of the diffuse large BCL variety. CONCLUSIONS: Most non-MF/SS PCL, SCL, and POL can be adequately categorized according to the 2005-WHO/EORTC and 2016-WHO classification systems, even when dealing with clinically atypical cases. The relative frequencies in our cohort hold closer similarities to Asian registries than from those of Europe/USA, supporting the concept of individual and/or racial susceptibility, and the notion of geographical variances in the rate of lymphomas. In particular, such disparity may arise from viral-induced lymphomas which might show partial geographical restriction.

Epidemiology of adverse cutaneous drug reactions. A prospective study in hospitalized patients.

BACKGROUND: Drug reactions are commonly present in the skin; however, their frequency in our setting is unknown. METHODS: A 10-month prospective cohort study including all hospitalized patients was designed. Those with adverse cutaneous drug reactions (ACDR) were clinically identified. RESULTS: Thirty five drug reactions (prevalence of 0.7%) were seen among 4785 (2713 females, 2072 males) discharged patients. According to Begaud's imputability criteria, the reactions were most likely attributed to a drug in 4.87%, likely in 41.46% and possible in 53.65%. The most commonly seen dermatoses were morbilliform rash 51.2%, urticaria 12.2% and erythema multiforme 4.9%. Drugs most frequently associated with ACDR were amoxicillin clavulanate (8), amphotericin B (2) and metamizole (4). Expressed as risk by 1000 day-doses (Dd: the risk a patient has of developing an ACDR after receiving 1 day of treatment with the drug): amoxicillin clavulanate Dd 7.7, amphotericin B Dd 4.8 and metamizole Dd 3.7. Immunosuppressed patients were most frequently affected. Notably, patients with systemic lupus erythematosus (SLE) had a 4.68 higher risk (CI 95% 1.794-12.186 p <0.001) of developing an ACDR. AIDS patients showed a risk of 8.68 (CI 95% 2.18-33.19 p <0.001). Non-Hodgkin's lymphoma patients also had an increased risk of developing an ACDR. Six of the 35 identified cases were patients who had been hospitalized due to a severe drug reaction (1.3/1000 patients); one died from complications directly related to the ACDR, representing a 16.6% mortality rate among those admitted for an ACDR and 0.02% among the global mortality. CONCLUSIONS: We have a low prevalence of drug reactions compared to data reported in the literature. Pharmacovigilance with special attention to immunosuppressed SLE or AIDS patients is stressed.

Diagnostic challenge of glucagonoma: case report and literature review.

OBJECTIVE: To report the diagnostic difficulties encountered in a case of glucagonoma. METHODS: We provide a literature review and present the clinical findings, pertinent laboratory data, and results of related studies in a patient with a glucagonoma. RESULTS: A 54-year-old-man, with no relevant history of endocrine disorders, presented to the hospital with a 5-year history of recurrent stomatitis and glossitis, a more recent weight loss of 11.5 kg, and recurrent pruritic maculae on the scalp in conjunction with raised erythematous maculae in the scrotal region and perineum that gradually migrated to the distal extremities, becoming bullous and painful. The patient was hospitalized, and because of the dermatologic findings suggestive of necrolytic migratory erythema, the presence of a glucagonoma was suspected. His blood glucose levels were in the normal range. Glucagon levels were found to be elevated, and imaging studies confirmed the presence of an enlarged mass in the pancreatic tail, without evidence of extension to surrounding structures. Liver metastatic lesions were also excluded. After surgical removal of the tumor, the skin and oral mucosal lesions disappeared spontaneously. The histologic appearance and immunohistochemical staining results confirmed the diagnosis of a glucagonoma. Subsequently, all related symptoms resolved, and the glucagon levels normalized. CONCLUSION: The diagnosis of glucagonoma is often delayed. Clinicians should be aware of the unusual initial manifestations of this tumor and the potential for less than a full spectrum of the characteristic features of the glucagonoma syndrome.

[The skin and the digestive tract]. / La piel y el aparato digestivo.

Dermatology and Gastroenterology are medical subspecialties close related. There are diseases with same physiopathological mechanisms. When these diseases express it is possibly to see internal and external sings. In this review we analyzed different dermatological pathologies related to gastroenterology diseases. Knowing those dermatological clinical manifestations it is possible to make gastroenterological diseases diagnosis.

Incidence and risk factors for cutaneous adverse drug reactions in an intensive care unit.

OBJECTIVE: To evaluate the incidence of adverse cutaneous drug reactions in intensive care unit patients. DESIGN: Cohort study. SETTING: General adult intensive care unit of an institutional tertiary care hospital. PATIENTS: Patients in the intensive care unit during a consecutive 8-month period were examined for adverse cutaneous drug reactions. RESULTS: Patients in the intensive care unit have an incidence of 11.6% of adverse cutaneous drug reactions. Associated risk factors were female gender, obesity, age over 60 and immune dysregulation (systemic lupus erythematosus, dysthyroidism, and antiphospholipid antibodies syndrome). Few patients had previous history of adverse cutaneous drug reactions. Antimicrobials were the main drug involved. Morbilliform rash followed by urticary were the most frequently observed reactions. Interestingly, over 50% of patients with massive edema -independent of etiology- died. CONCLUSIONS: Intensive care unit patients are particularly at risk for developing an adverse cutaneous drug reaction.

Genetic association of IFN-γ +874T/A polymorphism in Mexican patients with drug-induced Stevens-Johnson syndrome/toxic epidermal necrolysis.

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) are rare, but potentially life-threatening diseases, characterized by widespread epidermal necrosis and are predominantly drug induced. There is a paucity of data regarding the role of cytokine and cytokine receptors polymorphisms in the pathoimmunology of SJS/TEN. The aim of this study was to investigate the role of TNF-α-308, IFN-γ +874, IL-10-1082, IL-13 Arg130Gln, and IL-4R Gln551Arg gene polymorphisms in SJS/TEN in Mexican Mestizo patients. Twenty-nine unrelated SJS/TEN patients and 128 unrelated healthy individuals were studied. Genomic extraction was carried out from complete blood samples using the salting out method. The PCR-RFLP method was used to amplify the following polymorphisms: TNF-α-308, IFN-γ +874, IL-10-1082, IL-13 Arg130Gln, and IL-4R Gln551Arg. TNF-α-308, IL-10-1082, IL-13 Arg130Gln, and IL-4R Gln551Arg polymorphisms were not associated with the genetic susceptibility to SJS/TEN. The distribution of TT, TA, AA genotypes of IFN-γ +874 was significantly different in SJS/TEN patients compared with controls (pC = 0.012). TA and AA genotypes were grouped to highlight the differences between patients and controls given by the absence of the AA genotype in the group of patients (pC = 0.03, OR = 3.61 95 % CI 1.20-11.6). This preliminary study suggests that IFN-γ +874 T/A polymorphism is associated with SJS/TEN.

Superficial mycotic infections of the foot in a native pediatric population: a pathogenic role for Trichosporon cutaneum?

Superficial mycotic infections of the feet are usually caused by Tricophyton rubrum, predominantly affecting adults and resulting from the use of occlusive footwear. We carried out a mycologic study of superficial foot infections in a rural school in Mexico where most people wear a leather, nonocclusive sandal. Forty students had clinical signs of 50 fungal infections of the foot: 39 athlete's foot and 11 onychomycosis. Thirty-one boys and 9 girls were studied. Hyphae were seen in 11 cases of athlete's foot and 5 of onychomycosis. Twenty-one cultures were positive (42%). The most frequently isolated fungi were the opportunistic Trichosporon cutaneum in 42.8%, Candida sp. (23.8%), Trichophyton mentagrophytes (23.8%), and Candida glabrata (9.5%). Superficial mycotic infections of the feet and nails were most frequent in children and adolescents who usually wear nonocclusive shoes. The most frequent pathogens were Candida sp. and T. mentagrophytes. It is interesting to note the prevalence of T. cutaneum that has recently been implicated in mycoses of the feet and nails. We did not isolate T. rubrum in any patient.

Incidence and risk factors for cutaneous adverse drug reactions in an intensive care unit / Incidencia y factores de riesgo en las reacciones adversas medicamentosas de tipo cutáneo en la unidad de cuidados intensivos

Objective. To evaluate the incidence of adverse cutaneous drug reactions in intensive care unit patients. Design. Cohort study. Setting. General adult intensive care unit of an institutional tertiary care hospital. Patients. Patients in the intensive care unit during a consecutive 8-month period were examined for adverse cutaneous drug reactions. Results. Patients in the intensive care unit have an incidence of 11.6% of adverse cutaneous drug reactions. Associated risk factors were female gender, obesity, age over 60 and immune dysregulation (systemic lupus erythematosus, dysthyroidism, and antiphospholipid antibodies syndrome). Few patients had previous history of adverse cutaneous drug reactions. Antimicrobials were the main drug involved. Morbilliform rash followed by urticary were the most frequently observed reactions. Interestingly, over 50% of patients with massive edema -independent of etiology- died. Conclusions. Intensive care unit patients are particularly at risk for developing an adverse cutaneous drug reaction.

Se realizó un estudio de cohorte en la Unidad de Terapia Intensiva (UTI) de un hospital de tercer nivel para evaluar la incidencia de reacciones cutáneas adversas a drogas. Se examinaron todos los pacientes internados en dicha unidad durante un periodo consecutivo de ocho meses. Observamos una incidencia de reacciones adversas a medicamentos de 11.6%. Los factores de riesgo asociados fueron sexo femenino, obesidad, edad mayor a 60 años y alteraciones inmu-nológicas (lupus eritematoso sistémico, distiroidismo y síndrome de antifosfolípido). Los antimicrobianos fueron los principales medicamentos involucrados. La erupción morbiliforme y la urticaria fueron las reacciones más frecuentes. Un hallazgo interesante fue que más de 50% de los pacientes con anasarca fallecieron. Concluimos que los pacientes internados en la UTI son particularmente susceptibles para desarrollar una reacción adversa cutánea a medicamentos.