A case of choroidal neovascularization as a first manifestaion of systemic lupus erythematosus.

BACKGROUND: To report a rare occurrence of pigment epitheliopathy associated with choroidal neovasculization as a first manifestation of systemic lupus erythematosus. CASE PRESENTATION: A 54-year-old female, with no prior medical history, sought a second opinion due to sudden drop in vision in her right eye to 20/80. Slit lamp examination was normal. Fundus examination revealed the presence of a subretinal hemorrhage in the macular area. Fundus imaging including optical coherence tomography and fluorescein angiography showed multifocal retinal pigment epitheliopathy associated with choroidal neovascularization (CNV). The patient had received an intravitreal injection of Bevacizumab 2 weeks ago. It was decided to complete the loading dose regimen with two additional Bevacizumab injections, and the first injection was done 2 weeks after her presentation. Two weeks later, the patient reported a rash on her cheeks, painful joints, and purpura. Systemic workup revealed positive ANA, anti-cardiolipin antibodies, and decreased complement levels, with negative anti-histone antibodies. This led to the diagnosis of systemic lupus erythematosus (SLE) based on the "Systemic Lupus International Collaborating Clinics" criteria. The patient was treated with 50 mg of prednisolone which was then tapered. 1 month after the third injection, an showed a total resolution of the sub-retinal fluid with an improvement of vision to 20/20. No recurrence was observed during follow-up. CONCLUSION: Based on the findings from the fundus exam and imaging, systemic symptoms and the blood work-up, we postulate that the pigment epitheliopathy associated with choroidal neovascularization was related to the vaso-occlusive disease at the level of the choroid that can be part of SLE vasculopathy. To our knowledge, this represents the first case in which pigment epitheliopathy and CNV were the primary manifestations of SLE.

Analysis of ocular injury 1-year outcome in survivors of Beirut Port ammonium nitrate blast.

PURPOSE: Ascertain the 1-year outcome of patients who sustained open eye injuries from the Beirut Port ammonium nitrate (AN) explosion, one of the most powerful non-nuclear explosions in history. METHODS: Retrospective chart review of the operated eyes in 2 major eye hospitals. RESULTS: Out of 42 patients with open globe injury that was originally sutured, 29 patients (34 eyes) were followed at the 1-year mark. The initial vision in logMAR (mean ± SD) was 2.93 ± 0.87 (hand motion equivalent) and the final vision was 1.80 ± 1.47 (counting finger 2 m equivalent). No light perception (NLP) vision was noted in 12 eyes on presentation and 10 eyes remained so, while 2 eyes reached light perception (LP) vision. Eight eyes had an intraoperative expulsive choroidal hemorrhage (7 NLP and 1 LP both pre- and postoperatively), and 6 of the 8 developed phthisis. All eyes that developed phthisis had NLP preoperatively and postoperatively. Ocular Trauma Score (OTS) correlated inversely with both initial and final vision (p < 0.001). Zone of injury inversely correlated with initial vision (p = 0.02) and positively with final vision (p < 0.001). Final vision was significantly worse in zone 3 vs. zones 1 and 2 (3.2 ± 0.5) vs. 0.9 ± 1.1) (p < 0.001) injuries, as was the initial vision (3.3 ± 0.5 vs. 2.7 ± 0.8; p = 0.002). CONCLUSION: The OTS, which provides prognostic information for serious ocular trauma, also yields valuable prognostic information for AN-associated ocular injuries. Expulsive choroidal hemorrhage and NLP vision at presentation remain very poor prognostic signs.

EFFICACY OF INTRAVITREAL RANIBIZUMAB INJECTIONS IN THE TREATMENT OF VITREOUS HEMORRHAGE RELATED TO PROLIFERATIVE DIABETIC RETINOPATHY.

PURPOSE: To investigate the efficacy of intravitreal ranibizumab injections in proliferative diabetic retinopathy associated with vitreous hemorrhage (VH). METHODS: A prospective study including patients with proliferative diabetic retinopathy who presented with persistent VH. Vitreous hemorrhage was graded into mild, moderate, and severe. Patients were randomized into two groups: the ranibizumab group was treated with intravitreal injections of ranibizumab and the control group was assigned to observation alone. Vitrectomy was performed if there was any aggravation of the VH in patients with mild, moderate, and severe VH or in the absence of improvement by 16 weeks in patients with moderate and severe VH. RESULTS: The ranibizumab group included 71 patients and the control group included 62 patients. There was a statistically significant difference in the vitrectomy rate in patients with mild-to-moderate VH (5 patients [7.04%] and 12 patients [19.35%], respectively; P = 0.04). However, there was no statistically significant difference in the overall vitrectomy rate, and in the vitrectomy rate in severe VH (17 [23.94%] and 12 [16.90%] patients in the ranibizumab group vs. 22 [35.48%] and 10 [16.13%] patients in the control group, P = 0.14 and P = 0.83, respectively). Recurrence of the VH occurred in 22 patients in the ranibizumab group and 29 patients in the control group (P = 0.06). Better visual acuity measurements were recorded on all follow-up visits in the ranibizumab group (P ≤ 0.04). CONCLUSION: Intravitreal ranibizumab injections could be considered in proliferative diabetic retinopathy patients with mild and moderate VH.

VITREORETINAL SURGERY WITH SILICONE OIL TAMPONADE IN PRIMARY UNCOMPLICATED RHEGMATOGENOUS RETINAL DETACHMENT: Clinical Outcomes and Complications.

BACKGROUND: To determine the anatomical and functional outcomes and possible complications after pars plana vitrectomy (PPV) with silicone oil (SO) tamponade in primary uncomplicated rhegmatogenous retinal detachments. METHODS: This is a prospective observational study. Overall, 62 consecutive patients who underwent surgical repair by PPV and SO injection for primary uncomplicated rhegmatogenous retinal detachment between January 01, 2006 and April 30, 2012 were followed. In general, PPV was chosen over scleral buckling when a significant cataract or a vitreous hemorrhage prevented adequate fundus visualization. Silicone oil was chosen over gas tamponade in patients living at 1,000 meters above the sea level, where SF6 or C3F8 tamponade could not be performed because of the risk of acute increase of intraocular pressure (IOP). One thousand centistokes SO was used in all eyes. At all visits, patients had a detailed ocular history and thorough bilateral evaluation, including best-corrected visual acuity, anterior segment examination, and IOP measurements by aplanation and fundus examination. Outcomes were assessed at 1 day, 1 week, 1 month, 3 months, 6 months, and every 6 months thereafter. Increased IOP was defined as an IOP of more than 21 mmHg. RESULTS: Anatomical success rate, final best-corrected visual acuity, IOP elevation, cataract formation, and other complications were the main outcome measures. This study included 62 eyes of 62 patients (41 men and 21 women) that underwent retinal detachment repair by PPV and SO injection. The age at the time of intervention was 57.6 ± 10.5 years (mean ± standard deviation; range, 34-79 years). All patients were whites. Mean follow-up was 24.5 ± 17.3 months (range, 6-70 months). Anatomical success rate defined as retinal reattachment 6 months after SO removal was 93.5%. Final BCVA was improved in 55 eyes (88.7%), with a mean of 4 Snellen lines, unchanged in 5 (8.1%), and worse in 2 eyes (3.2%), with a mean of 3 Snellen lines. Mean duration of SO tamponade was 5.12 ± 2.37 months (range, 2-12 months). From the 30 eyes that were still phakic after vitrectomy, 24 eyes (80.0%) underwent cataract surgery within a period of 7.37 ± 3.00 months (range, 2-13 months). Thirty-five eyes (56.5%) had an increase in IOP during the follow-up period. Thirty-one patients had transient ocular hypertension requiring topical treatment during the immediate postoperative period (one month). Only 1 eye (2.9%) required filtrating drainage surgery for IOP control. No eyes developed optic neuropathy secondary to IOP elevation. CONCLUSION: Pars plana vitrectomy with SO injection seems to be a safe and efficient surgical approach in the treatment of primary uncomplicated rhegmatogenous retinal detachment in patients living in high altitude (>1,000 m). Also, PPV and SO injection are associated with good anatomical and functional outcomes in our series. Reattachment rates are high, and rates of proliferative vitreoretinopathy are low. Cataract formation and elevated IOP represent frequent but successfully controlled complications.

Prevalence of and risk factors for penile infection by high-risk human papillomavirus among men infected with HIV.

This study aimed to determine the prevalence of and risk factors for high-risk human papillomavirus (HPV) genital infection and precursor lesions of penile cancer among patients infected with human immunodeficiency virus (HIV). In total, 276 men with a mean age of 34.6 years were included. All participants were subjected to peniscopic examination under magnification, collection of genital exfoliated cells for detecting HPV types using Hybrid Capture, and biopsy surgery of clinically observable lesions and aceto-white areas for histopathological studies. The prevalence of high-risk HPV types was 43%. Peniscopicy showed clinically visible lesions or aceto-white areas in 75/276 participants (27%), of which genital warts were the most common (22/75; 29%). HIV-positive (HIV(+) ) men with CD4(+) T-cell counts <200 cells/mm(3) showed a higher prevalence of penile lesions. Multivariate logistic regression was applied to identify independent risk factors for high-risk HPV types. The results showed that high-risk HPV was associated with lower education level (OR = 1.89, 95% CI: 1.15-3.13), illicit drug use (OR = 1.80, 95% CI: 1.03-3.14), mulatto ethnicity (OR = 2.51, 95% CI: 1.38-4.54), heterosexual orientation (OR = 2.12, 95% CI: 1.30-3.47) symptomatic AIDS (OR = 2.80, 95% CI: 1.65-4.77), AIDS-associated opportunistic infections (OR = 2.92, 95% CI: 1.78-4.78), on HAART (OR = 2.91, 95% CI: 1.78-4.77), and CD4(+) T-cell count <200 cells/mm(3) (OR = 3.31, 95% CI: 1.84-5.96). Immunocompromised men were more susceptible to developing penile lesions associated with high-risk HPV types.

Clinical and laboratorial study of HPV infection in men infected with HIV.

OBJECTIVES: To determine the prevalence of precursor lesions of penile cancer, to establish the concordance of diagnostic techniques (PCR, Hybrid Capture (HC) and peniscopy with acetic acid 5%) in the diagnosis of Human Papilloma Virus (HPV) of the penis of men infected with HIV and to evaluate the influence of the immune status. PATIENTS, METHODS AND RESULTS: 276 men were studied, with a median age of 34.6 years. Prevalence of High Risk HPV, Low Risk HPV and infection with both, according to HC, was 43%, 32% and 22%, respectively. PCR showed 50% of positivity for HPV DNA. Peniscopy was positive in 27% of individuals. Peniscopy showed good specificity and low sensitivity for the detection of penile HPV, and low concordance with PCR. Men with white lesions had a 3.6 higher relative risk of positivity for HPV. The most common clinical lesion observed was vegetation, identified in 29% of patients. PCR and HC techniques showed high sensitivity for HPV DNA and there was an excellent correlation between them. Immunosuppressed individuals with CD4 < 200 cells/mm(3) had the highest prevalence of premalignant lesions that were observed in 10% of the studied individuals. CONCLUSIONS: Peniscopy was important for identification and treatment of subclinical lesions. PCR and HC techniques were sensitive methods for the detection of HPV DNA with high concordance. Severely immunosuppressed individuals showed a higher prevalence of pre-malignant lesions of the penis.

Chlamydia trachomatis in human immunodeficiency virus-infected men treated at a referral hospital for sexually transmitted diseases in the Amazonas, Brazil.

OBJECTIVES: The aim of the present study was to determine the Chlamydia trachomatis prevalence and to identify the demographic, behavioural and clinical factors associated with C. trachomatis in human immunodeficiency virus infected men. STUDY: This was a cross-sectional study of C. trachomatis prevalence among human immunodeficiency virus-infected men enrolled at the Outpatient clinic of acquired immunodeficiency syndrome of the Fundação de Medicina Tropical Dr. Heitor Vieira Dourado in Manaus, Amazonas, Brazil. C. trachomatis deoxyribonucleic acid from urethral samples was purified and submitted to real time polymerase chain reaction to identify the presence of C. trachomatis. RESULTS: A total of 276 human immunodeficiency virus-infected men were included in the study. The prevalence of C. trachomatis infection was 12% (95% confidence interval 8.1%-15.7%). The mean age of the participants was 34.63 (standard deviation 10.80) years. Of the 276 human immunodeficiency virus-infected men, 93 (56.2%) had more than one sexual partner in the past year and 105 (38.0%) reported having their first sexual intercourse under the age of 15 years. Men having sex with men and bisexuals amounted to 61.2% of the studied population. A total of 71.7% had received human immunodeficiency virus diagnosis in the last three years and 55.1% were using antiretroviral therapy. Factors associated with C. trachomatis infection in the logistic model were being single (p<0.034), men having sex with men (p<0.021), and having previous sexually transmitted diseases (p<0.001). CONCLUSION: The high prevalence of C. trachomatis infection among human immunodeficiency virus-infected men highlights that screening human immunodeficiency virus-infected men for C. trachomatis, especially among men having sex with men, is paramount to control the spread of C. trachomatis infection.

Obesity and dyslipidemia in patients with psoriasis treated at a dermatologic clinic in Manaus.

BACKGROUND: Psoriasis is a chronic inflammatory disease of multifactorial etiology, with participation of genetic, autoimmune and environmental factors. Recent studies have demonstrated the role of inflammatory cells and mediators in the pathogenesis of psoriasis, which is now defined as a systemic and autoimmune inflammatory disease that may be associated with other diseases of inflammatory nature. OBJECTIVES: To evaluate the occurrence of obesity and dyslipidemia in patients with psoriasis treated at a dermatology clinic in Manaus. METHODS: We performed a prospective descriptive study to assess the prevalence of obesity and dyslipidemia in patients with psoriasis. Besides the recommended dermatological care, a physical examination was performed to measure weight, height and waist circumference. RESULTS: We included 72 patients, 44 (61.1%) female and 28 (38.9%) male, with a mean age of 51.0 years ± 15.9 years. As for body mass index (BMI), 16 (22.2%) were overweight and 20 (27.8%) were obese. In the analysis of waist circumference in relation to gender, we found that 79.5% of women surveyed had central obesity, a percentage statistically higher than that observed among men (42.9%) at the 5% level of significance (p = 0.001). Regarding the diagnosis of dyslipidemia, 29 (65.9%) females and 22 (78.6%) males showed alterations in lipid profile. CONCLUSIONS: The occurrence of dyslipidemia and obesity in patients with psoriasis can affect life quality and expectancy, increasing the risk of systemic and metabolic diseases, which makes periodic investigation of these comorbidities in patients with psoriasis mandatory.

Extra ocular sebaceous adenocarcinoma in HIV-positive patient--case report.

Sebaceous adenocarcinoma is a rare adnexal tumor that can affect the skin and is divided into ocular, a more common form and extra ocular, of a rarer occurrence. We report the case of a patient diagnosed with Acquired Immune Deficiency Syndrome (AIDS) who developed an extra ocular, bulky and fast-growing sebaceous adenocarcinoma on the face. The literature has suggested that transplanted patients and HIV-positive patients have an excess risk for developing adnexal tumors, including sebaceous adenocarcinoma.

Multifocal paracoccidioidomycosis: a diagnostic challenge due to late cutaneous manifestation.

Paracoccidioidomycosis is an endemic systemic mycosis in Brazil, frequent in the rural areas and often in adult men. It is reported the case of a farmer, who is an illicit drugs' user, with insidious manifestations affecting kidneys, lungs, lymphonodes, bones and lately, the skin, with a delay of more than one year in the diagnosis and effective therapy It is important to include paracoccidioidomycosis as differential diagnosis, even in the absence of cutaneous lesions, for early recognition and treatment, given the high mortality of this entity.

Chlamydia trachomatis in human immunodeficiency virus-infected men treated at a referral hospital for sexually transmitted diseases in the Amazonas, Brazil

OBJECTIVES: The aim of the present study was to determine the Chlamydia trachomatis prevalence and to identify the demographic, behavioural and clinical factors associated with C. trachomatis in human immunodeficiency virus infected men. STUDY: This was a cross-sectional study of C. trachomatis prevalence among human immunodeficiency virus-infected men enrolled at the Outpatient clinic of acquired immunodeficiency syndrome of the Fundação de Medicina Tropical Dr. Heitor Vieira Dourado in Manaus, Amazonas, Brazil. C. trachomatis deoxyribonucleic acid from urethral samples was purified and submitted to real time polymerase chain reaction to identify the presence of C. trachomatis. RESULTS: A total of 276 human immunodeficiency virus-infected men were included in the study. The prevalence of C. trachomatis infection was 12% (95% confidence interval 8.1%-15.7%). The mean age of the participants was 34.63 (standard deviation 10.80) years. Of the 276 human immunodeficiency virus-infected men, 93 (56.2%) had more than one sexual partner in the past year and 105 (38.0%) reported having their first sexual intercourse under the age of 15 years. Men having sex with men and bisexuals amounted to 61.2% of the studied population. A total of 71.7% had received human immunodeficiency virus diagnosis in the last three years and 55.1% were using antiretroviral therapy. Factors associated with C. trachomatis infection in the logistic model were being single (p<0.034), men having sex with men (p<0.021), and having previous sexually transmitted diseases (p<0.001). CONCLUSION: The high prevalence of C. trachomatis infection among human immunodeficiency virus-infected men highlights that screening human immunodeficiency virus-infected men for C. trachomatis, especially among men having sex with men, is paramount to control the spread of C. trachomatis infection. .

Siringocistoadenoma papilífero localizado na coxa / Syringocystadenoma papilliferum located in the thigh

Siringocistadenoma papilífero é tumor benigno raro, mais comum em couro cabeludo e face. Pode apresentar-se como lesão independente ou associada ao nevo sebáceo de Jadassohn. Foram relatados na literatura raros casos desse tumor com localização na coxa. Descrevemos o caso de uma paciente com siringocistadenoma papilífero distinguido por seu componente apócrino intradérmico tubular papilífero.

Syringocystadenoma papilliferum is a rare, benign tumor, most common in the scalp and face. It can present as an independent lesion or be associated with nevus sebaceous of Jadassohn. Rare cases of this tumor located in the thigh have been reported in the literature. The present article reports the case of a patient with syringocystadenoma papilliferum, distinguished by its intradermal tubular apocrine papillary component.

Obesity and dyslipidemia in patients with psoriasis treated at a dermatologic clinic in Manaus / Obesidade e dislipidemia em pacientes com psoriase atendidos num ambulatorio de dermatologia de Manaus

BACKGROUND: Psoriasis is a chronic inflammatory disease of multifactorial etiology, with participation of genetic, autoimmune and environmental factors. Recent studies have demonstrated the role of inflammatory cells and mediators in the pathogenesis of psoriasis, which is now defined as a systemic and autoimmune inflammatory disease that may be associated with other diseases of inflammatory nature. OBJECTIVES: To evaluate the occurrence of obesity and dyslipidemia in patients with psoriasis treated at a dermatology clinic in Manaus. METHODS: We performed a prospective descriptive study to assess the prevalence of obesity and dyslipidemia in patients with psoriasis. Besides the recommended dermatological care, a physical examination was performed to measure weight, height and waist circumference. RESULTS: We included 72 patients, 44 (61.1%) female and 28 (38.9%) male, with a mean age of 51.0 years ± 15.9 years. As for body mass index (BMI), 16 (22.2%) were overweight and 20 (27.8%) were obese. In the analysis of waist circumference in relation to gender, we found that 79.5% of women surveyed had central obesity, a percentage statistically higher than that observed among men (42.9%) at the 5% level of significance (p = 0.001). Regarding the diagnosis of dyslipidemia, 29 (65.9%) females and 22 (78.6%) males showed alterations in lipid profile. CONCLUSIONS: The occurrence of dyslipidemia and obesity in patients with psoriasis can affect life quality and expectancy, increasing the risk of systemic and metabolic diseases, which makes periodic investigation of these comorbidities in patients with psoriasis mandatory. .

FUNDAMENTOS: A psoríase é uma doença inflamatória crônica, com etiologia multifatorial, com participação de fatores genéticos, auto-imunes e ambientais. Estudos recentes demonstram o papel de células e mediadores inflamatórios na patogênese da psoríase, que passou a ser definida como uma afecção inflamatória sistêmica e auto-imune, podendo associarse a outras doenças de natureza inflamatória. OBJETIVOS: Avaliar a ocorrência de obesidade e dislipidemia em pacientes com psoríase atendidos num ambulatório de dermatologia de Manaus. MÉTODOS: Foi realizado estudo descritivo e prospectivo para avaliar a ocorrência de obesidade e dislipidemia em pacientes com psoríase. Além do atendimento dermatológico preconizado, foi realizado exame físico com medida de peso, altura e circunferência abdominal. RESULTADOS: Foram incluídos 72 pacientes, sendo 44 (61,1%) do sexo feminino e 28 (38,9%) do sexo masculino, com média de idade de 51,0 anos ± 15,9 anos. Quanto ao índice de massa corporal, 16 (22,2%) apresentavam sobrepeso e 20 (27,8%), obesidade. Na análise da circunferência abdominal em relação ao gênero, observou-se que 79,5% das mulheres examinadas apresentavam obesidade central, percentual estatisticamente maior que o observado entre os homens (42,9%), ao nível de 5% de significância (p= 0,001). Em relação ao diagnóstico de dislipidemia, 29 (65,9%) do sexo feminino e 22 (78,6%) do masculino apresentaram alteração no lipidograma. CONCLUSÕES: A ocorrência de dislipidemia e obesidade nos pacientes com psoríase pode alterar a qualidade e expectativa de vida, aumentando o risco de doenças sistêmicas e metabólicas, o que torna obrigatória a investigação periódica dessas ...

Extra ocular sebaceous adenocarcinoma in HIV-positive patient - case report / Adenocarcinoma sebaceo extra-ocular em paciente HIV positivo - relato de caso

Sebaceous adenocarcinoma is a rare adnexal tumor that can affect the skin and is divided into ocular, a more common form and extra ocular, of a rarer occurrence. We report the case of a patient diagnosed with Acquired Immune Deficiency Syndrome (AIDS) who developed an extra ocular, bulky and fast-growing sebaceous adenocarcinoma on the face. The literature has suggested that transplanted patients and HIV-positive patients have an excess risk for developing adnexal tumors, including sebaceous adenocarcinoma.

Adenocarcinoma sebáceo é um tumor anexial raro que pode envolver a pele e é dividido em ocular, mais comum e extraocular, mais raro. Relatamos o caso de um paciente com diagnóstico de Síndrome da Imunodeficiência Adquirida que desenvolveu um adenocarcinoma sebáceo extra-ocular, na face, volumoso, de rápido crescimento. A literatura tem sugerido que pacientes transplantados e portadores do vírus da imunodeficiência humana têm um excesso de risco para o desenvolvimento de tumores anexiais, incluindo o Adenocarcinoma sebáceo.

Clinical and laboratorial study of HPV infection in men infected with HIV

OBJECTIVES: To determine the prevalence of precursor lesions of penile cancer, to establish the concordance of diagnostic techniques (PCR, Hybrid Capture (HC) and peniscopy with acetic acid 5%) in the diagnosis of Human Papilloma Virus (HPV) of the penis of men infected with HIV and to evaluate the influence of the immune status. PATIENTS, METHODS AND RESULTS: 276 men were studied, with a median age of 34.6 years. Prevalence of High Risk HPV, Low Risk HPV and infection with both, according to HC, was 43%, 32% and 22%, respectively. PCR showed 50% of positivity for HPV DNA. Peniscopy was positive in 27% of individuals. Peniscopy showed good specificity and low sensitivity for the detection of penile HPV, and low concordance with PCR. Men with white lesions had a 3.6 higher relative risk of positivity for HPV. The most common clinical lesion observed was vegetation, identified in 29% of patients. PCR and HC techniques showed high sensitivity for HPV DNA and there was an excellent correlation between them. Immunosuppressed individuals with CD4< 200 cells/mm3 had the highest prevalence of pre-malignant lesions that were observed in 10% of the studied individuals. CONCLUSIONS: Peniscopy was important for identification and treatment of subclinical lesions. PCR and HC techniques were sensitive methods for the detection of HPV DNA with high concordance. Severely immunosuppressed individuals showed a higher prevalence of pre-malignant lesions of the penis.

Paracoccidioidomicose sistêmica multifocal: desafio diagnóstico por manifestação cutânea tardia / Multifocal paracoccidioidomycosis: a diagnostic challenge due to late cutaneous manifestation

No Brasil, a paracoccidioidomicose é uma micose sistêmica endêmica frequente na zona rural e em homens adultos. É relatado caso em agricultor, usuário de drogas ilícitas, com manifestações insidiosas, atingindo rins, pulmões, gânglios, ossos e tardiamente pele, com atraso no diagnóstico e na terapêutica eficaz em mais de um ano. É importante incluir a paracoccidioidomicose como diagnóstico diferencial frente a um quadro sugestivo, mesmo na ausência de lesões cutâneas, para reconhecimento e tratamento precoce, em vista da elevada morbimortalidade desta entidade.

Paracoccidioidomycosis is an endemic systemic mycosis in Brazil, frequent in the rural areas and often in adult men. It is reported the case of a farmer, who is an illicit drugs' user, with insidious manifestations affecting kidneys, lungs, lymphonodes, bones and lately, the skin, with a delay of more than one year in the diagnosis and effective therapy It is important to include paracoccidioidomycosis as differential diagnosis, even in the absence of cutaneous lesions, for early recognition and treatment, given the high mortality of this entity.