Unknown primary Merkel cell carcinoma with cutaneous spread.

The authors present the case of a woman in the seventh decade of life with medical history of: left nephrectomy for renal tuberculosis and non-Hodgkin's lymphoma treated with chemotherapy (QT) and radiotherapy. She presented with a 2-month history of non-tender, left inguinal lymph node enlargement. Positron Emission Tomography (PET)-CT -scanshowed hypermetabolic inguinal and retroperitoneal lymphadenopathies, no primary tumour. On the second dermatological examination a pink, 2 cm plaque on the anterior left knee was noted. The histopathological analysis revealed Merkel cell carcinoma. The patient underwent two lines of systemic QT, with life-threatening toxicities limiting treatment. Followed overwhelming disease progression with lymphoedema and numerous skin metastases in the left lower limb. The patient received palliative care until death. The rare incidence of such neoplasia and its uncommon clinical presentation justifies reporting this case and highlights the importance of multidisciplinary teams in the management of cancer patients.

Extragenital Gonorrhoea in Men Who Have Sex with Men: A Retrospective Study in a STI Clinic in Lisbon, Portugal.

INTRODUCTION: Recent studies worldwide reveal a significant prevalence of extragenital infections by Neisseria gonorrhoeae among men who have sex with men. We aimed to analyse the frequency and characteristics of extragenital gonococcal infections diagnosed in men who have sex with men in a walk-in Sexually Transmitted Infection clinic in Lisbon, Portugal. MATERIAL AND METHODS: We conducted a cross-sectional, retrospective study of the anorectal and/or oropharyngeal Neisseria gonorrhoeae infections in men who have sex with men, diagnosed in our Sexually Transmitted Infection clinic between January 2014 and December 2016. RESULTS: We found extragenital infection in 87 cases of gonorrhoea identified in men who have sex with men in this period, including: 49 cases of anorectal disease, 9 of oropharyngeal disease, 13 cases of infection at both extragenital sites, and 16 of simultaneous extragenital and urogenital gonorrhoea. Patients' ages ranged from 17 to 64 years (median: 28 years). Forty-seven (54%) of the patients did not present with any extragenital symptoms. Thirty (35%) were human immunodeficiency virus-1-positive. DISCUSSION: Since most extragenital Neisseria gonorrhoeae infections are asymptomatic, they may be missed and go untreated unless actively investigated. Current international guidelines recommend the screening of gonorrhoea at extragenital sites in men who have sex with men because anorectal and oropharyngeal infections constitute a potential disease reservoir, and may facilitate transmission and/or acquisition of human immunodeficiency virus infection. CONCLUSION: Our results highlight the relevance of testing men who have sex with men for Neisseria gonorrhoeae at extragenital sites, regardless of the existence of local complaints. The implementation of adequate screening programmes in Portugal should be considered. We also reinforce the need to raise awareness in the population regarding the adoption of prophylactic measures against transmission of sexually transmitted infections during anal and/or oral sexual exposure.

Introdução: Estudos internacionais recentes revelam uma prevalência significativa de infeções extragenitais por Neisseria gonorrhoeae em homens que têm sexo com homens. Pretendemos analisar a frequência e caraterísticas das infeções gonocócicas extragenitais diagnosticadas em homens que têm sexo com homens numa consulta aberta de Infeções Sexualmente Transmissíveis em Lisboa, Portugal. Material e Métodos: Conduzimos um estudo observacional transversal, retrospetivo, das infeções anorrectais e/ou orofaríngeas por Neisseria gonorrhoeae em homens que têm sexo com homens, diagnosticadas na nossa consulta de Infeções Sexualmente Transmissíveis entre janeiro de 2014 e dezembro de 2016. Resultados: Detetámos infeção extragenital em 87 dos casos de gonorreia identificados em homens que têm sexo com homens no período analisado, incluindo: 49 casos de doença anorrectal, 9 de doença orofaríngea, 13 casos de infeção em ambas as localizações extragenitais, e 16 de gonorreia simultaneamente extragenital e urogenital. A idade dos doentes variou entre 17 e 64 anos (mediana: 28 anos). Quarenta e sete (54%) dos doentes não apresentavam qualquer sintoma extragenital. Trinta (35%) tinham também infeção pelo vírus da imunodeficiência humana-1. Discussão: Dado que a maioria das infeções extragenitais por Neisseria gonorrhoeae são assintomáticas, estas podem não ser diagnosticadas, e não tratadas, se não pesquisadas ativamente. Em várias normas de orientação clínica internacionais atuais é recomendado o rastreio da gonorreia em localizações extragenitais em homens que têm sexo com homens, visto que as infeções anorrectais e orofaríngeas constituem potenciais reservatórios da doença e podem facilitar a transmissão e/ou aquisição de infeção pelo vírus da imunodeficiência humana. Conclusão: Os nossos resultados apontam para a relevância de testar os homens que têm sexo com homens para a presença de Neisseria gonorrhoeae em localizações extragenitais, independentemente da existência de sintomas locais. A implementação de programas de rastreio adequados em Portugal deverá ser considerada. Relevamos também a necessidade de sensibilizar a população para a adoção de medidas profiláticas contra a transmissão de infeções sexualmente transmissíveis durante o contacto sexual anal e/ou oral.

The dark side of the light: Phototherapy adverse effects.

Phototherapy is a valuable therapeutic tool in Dermatology, but there may be drawbacks. Acute and long-term adverse effects, of variable severity, include skin erythema, xerosis, pruritus, blistering, altered pigmentation, photoaging, and photocarcinogenesis. Despite concerns over the carcinogenic potential of ultraviolet radiation, most studies have not found an increased risk of non-melanoma or melanoma skin cancer in patients treated with ultraviolet B (broadband and narrowband) and ultraviolet A1 phototherapy. These are therefore considered reasonably safe treatment modalities concerning the development of skin neoplasms, although caution and further investigation are warranted. Photoprotective measures, such as avoidance of concurrent sunlight exposure and covering skin areas not afflicted with disease, or more modern strategies, including phytochemical antioxidants and exogenous DNA repair enzymes, can minimize the hazards of phototherapy. Patients submitted to phototherapeutic regimens should undergo complete, careful dermatologic examination regularly and lifelong.

The dark side of the light: mechanisms of photocarcinogenesis.

Ultraviolet radiation (UVR) can have a beneficial biologic impact on skin, but it is also the most significant environmental risk factor for skin cancer development. Photocarcinogenesis comprises a complex interplay between the carcinogenic UVR, skin, and the immune system. UVB is absorbed by the superficial skin layers and is mainly responsible for direct DNA damage, which, if unrepaired, can lead to mutations in key cancer genes. UVA is less carcinogenic, penetrates deeper in the dermis, and mainly causes indirect oxidative damage to cellular DNA, proteins, and lipids, via photosensitized reactions. UVR not only induces mutagenesis, altering proliferation and differentiation of skin cells, but also has several immunosuppressive effects that compromise tumor immunosurveillance by impairing antigen presentation, inducing suppressive cells, and modulating the cytokine environment. This review focuses upon molecular and cellular effects of UVR, regarding its role in skin cancer development.

A cerebral abscess at first internist glance.

A 73-year-old man was transferred to the neurosurgery ward, with a presumptive diagnosis of cerebral abscess. The case was also discussed with the internists as internal medicine consultants. The neurosurgeons pointed out a right temporal lobe abscedated lesion on CT, but we noticed that the hypodense attenuation that usually surrounds the abscess wall (vasogenic oedema) extended to a broader, well-delimitated area, suggesting medium cerebral artery territory. The patient had left-sided hemiplegia with a confusional state and low-grade fever. Considering possible haematogenous dissemination, an echocardiography was performed, confirming mitral endocarditis. Blood cultures and aspirated pus isolated Escherichia coli. Investigating the patient's medical history, we learned he had been submitted to bladder catheterisation 7 weeks before for acute urinary retention due to benign prostatic hyperplasia, and empirically medicated for urinary tract infection. E. coli had also been isolated in a urine specimen at the time. The clinical history of the patient cancelled the pathogenesis of cerebral abscess.