Nódulos subcutáneos faciales de 3 meses de evolución.

Siliconomas are subcutaneous nodules that usuallyappear as a consequence of the migration of freesilicon implanted in other locations. They are morefrequent in women with abnormal breast implants,such as poly implant prostheses (PIP), but they may alsoappear after illegal injection of free silicone. We reporta 57-year-old woman who attended our Dermatologyclinic complaining of relapsing facial panniculitis ofunknown origin. After a thorough work-up, thesenodules were determined to be the consequence ofdermal filler made with fluid silicone, which had beeninjected 20 years prior. High frequency skin ultrasoundof one of the nodules showed a hyperechoic image,also known as "snowstorm," which was located in thesubcutaneous tissue. The disposition of silicone in thisplane obscures the view of any sonographic structurein the underlying plane. Cutaneous sonographyhas become one of the most useful non-invasivetechniques in diagnosis of filler complications andother inflammatory diseases. Combined treatmentwith prednisone and allopurinol was successful, withno recurrence after 1 year of follow-up.

Verrucous tumor mimicking squamous cell carcinoma in immunocompetent patient.

Mycobacteria cause a range of diseases in both immunocompetent and immunosuppressed individuals. An increase in non-tuberculous mycobacterial (NTM) infections targeting skin has been described. Many hypotheses have been developed in order to explain it: the increasing burden of immunocompromised individuals, immigration from endemic countries, improved laboratory identification techniques, and changes inhuman behavior that expose individuals to this NTM. Mycobacterium mucogenicum group comprises M. mucogenicum, Mycobacterium aubagnense, and Mycobacterium phocaicum. This group of organisms was first named Mycobacterium chelonae-like organism in 1982. Most clinically significant cases of those organisms involved catheter-related infections. Nevertheless, we report an interesting patient with a cutaneous infection produced by M. mucogenicum mimicking a squamous cell carcinoma; an excellent response to combined therapy with rifampicin and clarythromicin was observed.

Blitz Nevus: A Clinical Simulator of Melanoma.

A 17-year-old adolescent girl attended our clinic for a scheduled review of her nevus lesions. She complained about a lesion on the posterior region of her neck, which she had noticed approximately 2 years before. Even though it had not caused any symptoms, its appearance had changed according to her parents. The patient's medical history, as well as that of her family's, was unremarkable.

Asymptomatic and infiltrated plaque on the left cheek.

Centrofollicular B Cell lymphomas constitute 25% of non-Hodgkin lymphomas that originate in the skin. They are the second in frequency of those lymphomas with extranodal location after gastrointestinal B lymphomas. The primary cutaneous centrofollicular lymphoma is characterized by the neoplastic proliferation of centrocytes and centroblasts confined to the skin. The prognosis is considered excellent with low probability of extracutaneous dissemination. We present a patient recently diagnosed in our unit with a good response to radiotherapy and complete resolution of the tumor with mild atrophy of the site.

Resultados del uso de etanercept en pacientes con psoriasis / Results from the use of etanercept in psoriatic patients

La psoriasis es una enfermedad crónica, inflamatoria, mediada inmunológicamente, con una considerable repercusión en la calidad de vida de los pacientes. Su importancia, además, está dada, entre otros factores, por su elevada prevalencia en la población. Los avances en el conocimiento de la inmunopatología de esta enfermedad y de la biología molecular han permitido el desarrollo de nuevos fármacos que representan una nueva forma de abordar la situación de estos pacientes, y que se encuadran en la denominada terapia biológica. El etanercept se empleó por primera vez en estudios clínicos con seres humanos en 1992 y ya son varios cientos de miles los enfermos tratados en todo el mundo por diferentes afecciones. Actualmente, la Agencia Europea de Evaluación de Medicamentos tiene aprobada la indicación de etanercept en las siguientes enfermedades: 1. Psoriasis en placa en adultos (“adultos con psoriasis en placa, de moderada a grave, que no han respondido o que tienen contraindicada, o no toleran, otra terapia sistémica incluyendo ciclosporina, metotrexato o PUVA”); 2. Psoriasis pediátrica grave en placa. 3. Artritis psoriásica; 4. Artritis reumatoidea; 5. Artritis idiopática juvenil poliarticular; 6. Espondilitis anquilosante. Su utilización en la psoriasis, ya bien conocida, ha hecho que poco a poco empiecen a surgir cuestiones sobre su manejo en situaciones especiales que requieren tener en cuenta las particularidades de su aplicación (lactancia, vacunaciones, infecciones) que abordaremos en este trabajo...

Off-label uses of anti-TNF therapy in three frequent disorders: Behçet's disease, sarcoidosis, and noninfectious uveitis.

Tumoral necrosis factor α plays a central role in both the inflammatory response and that of the immune system. Thus, its blockade with the so-called anti-TNF agents (infliximab, etanercept, adalimumab, certolizumab pegol, and golimumab) has turned into the most important tool in the management of a variety of disorders, such as rheumatoid arthritis, spondyloarthropatties, inflammatory bowel disease, and psoriasis. Nonetheless, theoretically, some other autoimmune disorders may benefit from these agents. Our aim is to review these off-label uses of anti-TNF blockers in three common conditions: Behçet's disease, sarcoidosis, and noninfectious uveitis. Due to the insufficient number of adequate clinical trials and consequently to their lower prevalence compared to other immune disorders, this review is mainly based on case reports and case series.

[The impact of therapy with TNF-blockers on health-related quality of life in rheumatoid arthritis patients. A pilot study]. / Calidad de vida relacionada con la salud tras terapia anti-factor de necrosis tumoral alfa en pacientes con artritis reumatoide. Un estudio piloto.

INTRODUCTION: The aim of this pilot study was to evaluate the initial response to 16 weeks of treatment with infliximab and etanercept of disease activity and quality of life in a cohort of 37 patients with established rheumatoid arthritis. PATIENTS AND METHOD: Patients were selected from the Unit of Rheumatology in Hospital Clínico San Cecilio from Granada, refractory to conventional treatment with disease modifying antirheumatic drugs. To assess the disease activity, Disease activity score (DAS28) was used and the measurement of quality of life was evaluated with the Spanish version of the SF-36 Health Survey (SF-36) and the RA-specific questionnaire QoL Scale (Quality of Life in Rheumatoid Arthritis). RESULTS: Preliminary results show a significant decrease in inflammatory activity of the disease and consequently in HRQL scores. The comparison with the general reference population shows a deviation well below average, especially in the "physical function" dimension with a rising response pattern in all dimensions. The correlation between specific scores (QoL-RA scale) and generic ones (SF-36) for HQ-treatment also showed significance, especially with the physical aggregate. DISCUSSION: An important limitation of the present study is the number of patients and the duration of the treatment; despite this, improvements in functional parameters and quality of life are evident and remain roughly stable since the first weeks of treatment. This allow us to continue the study and increase the number of patients. CONCLUSIONS: The preliminary results obtained with TNF-blockers after 16 weeks of treatment in RA objectively show the effectiveness of these drugs and also the perception by the patients of the effect on their quality of life.

[Evaluation of bone mineral density, bone turnover markers, the OPG/RANKL system and sTNF-RI in Crohn's disease]. / Valoración de la densidad mineral ósea, marcadores de remodelado óseo, el sistema OPG/RANKL y el sTNF-RI en la enfermedad de Crohn.

INTRODUCTION: Patients with Crohn's disease are at risk of developing osteoporosis, a disease in which the inflammatory process seems to be gaining importance. We performed a cross-sectional study to evaluate bone metabolism, osteoclastogenic factors [receptor activator of NF-kB ligand (RANK-L) and osteoprotegerin (OPG)] and soluble tumor necrosis factor-α receptor I (sTNF-RI) in patients with Crohn's disease and to correlate the findings with the degree of disease activity. METHOD: Sixty-four patients with Crohn's disease from the province of Granada (Spain) were included in this study. Bone mineral density (BMD) was studied through dual X-ray absorptiometry. Immunoassay was used to assess markers of bone formation [bone alkaline phosphatase (bALP) and osteocalcin (OC)] and bone resorption [tartrate resistant acid phosphatase (TRAP) and carboxyterminal telopeptide of type I procollagen (CTX)] as well as RANKL, OPG and sTNF-RI. RESULTS: The percentage of patients with a Z-score ≤-2 in the femoral neck or lumbar spine was 20.3% and was higher in patients with active disease, although this difference was not significant. This percentage was only higher in patients receiving corticosteroids (11.1 vs. 9.1%; P=.001). Patients with the highest disease activity had higher TRAP levels. No significant differences were found in BMD but significant differences were found in TRAP levels with respect to C-reactive protein concentrations. No association was found between levels of OPG, RANKL and sTNF-RI and BMD or disease activity. CONCLUSIONS: A substantial proportion of our patients had low BMD. Levels of bone turnover markers suggested higher bone resorption, possibly in relation to disease activity, without a compensatory increase in bone formation.

[Vitamin D deficiency and bone mineral density in Crohn's disease]. / Déficit de vitamina D y densidad mineral ósea en la enfermedad de Crohn.

BACKGROUND AND OBJECTIVES: Inadequate serum levels of 25-hydroxyvitamin D (25OHD(3)) are deemed as a possible risk factor for osteoporosis in Crohn's disease (CD). Our aim is to determine the prevalence of inadequate serum levels of 25OHD(3) and its possible relationship with low bone mineral disease (BMD) in CD. PATIENTS AND METHODS: Sixty-four patients from the province of Granada (Spain) were enrolled. Serum levels of 25OHD3 and intact parathyroid hormone were measured. BMD was assessed by dual-energy x-ray absorptiometry at lumbar spine (LS) and femoral neck (FN). RESULTS: Almost 60% of patients showed inadequate serum levels of 25OHD(3), whereas only about 16% showed levels considered as adequate (≥30 ng/mL). Z-score at FN was ≤ -2 in 4.7% of patients and 20.3% at LS. Regarding T-score, 4.7 and 46.9% of patients met criteria for osteoporosis and osteopenia at FN, respectively, whereas 6.25 and 42.2% did it at LS, respectively. Patients with inadequate serum levels of 25OHD(3) had non-significant lower BMD, both at the LS and the FN. CONCLUSIONS: Prevalence of inadequate serum levels of 25-(OH)D was high in our series. A no statistically-significant tendency towards low BMD in patients with inadequate serum levels of 25-(OH)D both at the FN and the LS was observed.

[Functional level and quality of life in ankylosing spondylitis, pilot study after 16 weeks TNF blocker treatment]. / Nivel funcional y calidad de vida en espondilitis anquilosante. Estudio piloto tras 16 semanas de tratamiento anti-TNF.

BACKGROUND AND OBJECTIVES: The aim of the present study is to assess the impact of infliximab and etanercept, TNF-alpha (tumour necrosis factor-alpha blockers) on functional disability and quality of life in thirteen patients over 65 years-old with ankylosing spondylitis (AS). PATIENTS AND METHODS: We consecutively included patients over 65 years-old, attending our clinic from Rheumatology Service in Hospital Clínico de Granada. These patients were all refractory to conventional therapy with disease-modifying anti-rheumatic drugs (DMARD). Disease activity was assessed using BASDAI index (bath ankylosing spondylitis disease activity index). Functional disability was assessed using BASFI (bath ankylosing spondylitis functional index) and ASQol index (ankylosing spondylitis quality of life index). RESULTS: We present a pilot study with 13 patients over 65 years-old treated with TNF blockers for 16 weeks. A significant decrease in disease activity was observed. Mean values of VAS (visual analogue scale) pain scores and disease decreases significantly after treatment (from 6.72 to 3.67 and 6.15 to 2.79 respectively), less than 4, which is considered an acceptable BASDAI response. Functional ability (BASFI) and health related quality of life (HRQOL) improved significantly from 6.15 to 2.79 and 13.85 to 4.22. CONCLUSIONS: Our results are consistent with the data available in the literature about TNF blockers decreasing clinical signs of the disease. Disease activity had significantly decreased 16 weeks after the onset of TNF blocker therapy. Functionality and quality of life have been also improved in elderly people with AS.

Long-term evolution of cytophagic histiocytic panniculitis.

BACKGROUND: Cytophagic histiocytic panniculitis is a disorder manifested by multiple subcutaneous nodules, characterized by lobular panniculitis, and occasionally accompanied by severe systemic manifestations, which require an aggressive medical approach. Several case reports with a good response to immunosuppressive therapy in the acute phase can be found in the literature. OBJECTIVE AND CONCLUSION: Nevertheless, the long-term evolution of this entity has not been described yet, nor have precise recommendations regarding the most adequate posology and duration of therapy. We report the result of switching from a long-term cyclosporine therapy to tacrolimus in a patient with a severe form of cytophagic histiocytic panniculitis.