Asymptomatic reactivation of hepatitis B virus after prolonged treatment with etanercept.

Etanercept is an anti-tumor necrosis factor ɑ (anti-TNFɑ) drug used for treating immunomediated inflammatory diseases. It is least associated with hepatitis B virus (HBV) reactivation. We present a 71-year-old man with psoriasis refractory to phototherapy and acitretin, which led to etanercept monotherapy. Before anti-TNFɑ treatment, past contact with HBV was elicited; antibodies to HBc and HBs were positive whereas HBsAg was negative. Seven years after treatment initiation, while the patient was completely asymptomatic, a transaminase elevation was found and a reactivation of HBV was documented, with a high viral load of the virus. He started entecavir therapy and, after a 14-month follow-up, the viral load is still detectable at a low level, as well as HBsAg. We emphasize the late and asymptomatic reactivation of HBV associated with soluble anti-TNFɑ monotherapy. This case reinforces the importance of current recommendations for periodic monitoring of viral load and HBV markers in all patients that have had prior contact with HBV (positive anti-HBc), with or without indication for treatment of HBV (HBsAg and HBV-DNA negative).

[A cutaneous infection by Mycobacterium chelonae in a patient with rheumatoid arthritis]. / Infecção cutânea por Mycobacterium chelonae numa doente com artrite reumatóide.

There are no pathognomonic findings for cutaneous infection caused by Mycobacterium chelonae. The type and duration of therapy varies considerably among reports and no single antibiotic is considered the treatment of choice. A 61-year-old patient, suffering from rheumatoid arthritis (treated with metotrexate and salazopyrine), presented with violaceous nodules of the right leg that had been evolving for 6 months. She was underwent several skin biopsies. Tissue culture of the last showed an atypical mycobacteria, identified as M. chelonae. Despite improvement after a two-week course of treatment with clarithromycin, a switch to ciprofloxacin was made because of gastrointestinal intolerance. After 3 months, only slight improvement of the lesions was achieved and clarithromycin was reintroduced; significant clinical improvement occurred by the third month. Clarithromycin was continued a further two months until the patient quit on her own and. no recurrence was observed. Infections caused by M. chelonae frequently occur in the setting of immunological impairment. Contaminated water is the natural reservoir, but we were unable to establish the source of contamination. As was previously described, there was a significant delay between clinical presentation and diagnosis. Thus, a high index of suspicion and multiple biopsies with culture are of paramount importance to confirming the diagnosis.

Angiokeratomas of Fabry successfully treated with intense pulsed light.

Fabry disease (FD) is a rare X-linked lysosomal storage disorder resulting from the deficient activity of the enzyme alpha-galactosidase A. Angiokeratomas (AKs) are a frequent manifestation of this disease. They usually become apparent during childhood and can cause important cosmetic disability. Current treatment of this feature in the setting of FD has been mainly based on the application of laser systems, namely the argon laser, the variable pulse width 532-nm Nd:YAG laser, the 578-nm copper vapor laser and the flashlamp-pumped pulsed dye laser. We report the case of a 31-year-old Caucasian woman with a clinical and molecular (GLA p.R118C) diagnosis of FD, presenting multiple AKs scattered over the buttocks and thighs. She was treated with 10 sessions of intense pulsed light (IPL), with a 4-8-week interval between them. An almost complete clearance of the lesions was obtained, with no scars or significant complaints. No recurrence occurred during a 12-month follow-up period. The IPL source can be considered a suitable, effective and safe treatment modality for these cutaneous lesions that typically affect patients with FD, with no need for local anesthesia and with very satisfactory cosmetic results. To our best knowledge, there are no reports in the literature of Fabry's AKs treated with IPL.