Clinical spectrum of cutaneous manifestations in renal and renopancreatic recipients in two centers in Uruguay.

Uruguay, with a total population of 3,345,000 inhabitants, is the Latin American country with the second highest number of renal replacement therapies. Long-term immunosuppressant therapy is essential for graft survival but results in reduced immunosurveillance, leading to an increased risk of complications. A variety of dermatological manifestations and a large increase in nonmelanoma skin cancers have been reported in this population. The purpose of this study was to evaluate the frequency and clinical spectrum of cutaneous manifestations in renal and renopancreatic recipients in 2 reference centers in Uruguay. Two hundred and six renal or renopancreatic recipients between 21 and 77 years old were evaluated between September 2009 and September 2011. A total of 206 dermatoses were observed; 60% of the patients had at least 1 cutaneous manifestation. The most frequent dermatoses were cutaneous side effects due to immunosuppressive treatment (40.6%), followed by infections (26.1%), miscellaneous causes (18.9%), and malignant and premalignant lesions (14.4%). Transplant recipients represent a high-risk dermatological population. Physicians in transplant units should be aware of the importance of dermatological screening in order to promote early detection of skin cancer.

Melanocytic nevi with special features: clinical-dermoscopic and reflectance confocal microscopic-findings.

Histopathology is considered the 'gold' standard for the diagnosis and classification of melanocytic nevi, but the widespread use of in vivo diagnostic technologies such as dermoscopy and reflectance confocal microscopy (RCM), has enriched profoundly the knowledge regarding the morphological variability in nevi. This is because most morphological observations made via these in vivo tools are closely correlated with features seen in histopathology. Dermoscopy has allowed for a more detailed classification of nevi. As such, dermoscopy identifies four main morphologic groups (i.e. globular, reticular, starburst and structureless blue nevi), one group of nevi located at special body sites (i.e. face, acral, nail) and one group of nevi with special features. This latter category consists of nevi of the former categories, which are typified by peculiar clinical-histopathological findings. They can be subdivided into 'melanoma simulators' including combined nevi, recurrent nevi and sclerosing nevus with pseudomelanomatous features, 'targetoid' nevi (i.e. halo, cockade, irritated targetoid haemosiderotic and eczematous nevus) and uncommon histopathological variants such as desmoplastic, white dysplastic or ballon cell nevus. While the dermoscopic and RCM patterns of the former categories have been studied in detail, little is currently known about the clinical morphology of the heterogeneous group of 'special' nevi. In this article, we describe the clinical, dermoscopic and RCM features of 'special' nevi and review the current literature on this group of melanocytic proliferations.

Patrones dermatoscópicos de 158 nevos melanocíticos acrales en una población latinoamericana / Dermoscopic Patterns of 158 Acral Melanocytic Nevi in a Latin American Population

Introducción: Los nevos melanocíticos se encuentran con frecuencia en la piel volar acral. La diferenciación entre nevos y melanoma es imprescindible y a veces difícil, aunque la dermatoscopia ha permitido un diagnóstico más preciso de lesiones pigmentadas. Los patrones dermatoscópicos de lesiones en la piel volar acral han sido descritos en su mayoría en poblaciones europeas y asiáticas. La población latinoamericana es heterogénea, y en particular en el caso de los uruguayos, que provienen en gran parte de 3 distintas poblaciones. Objetivo: Describir los patrones dermatoscópicos de nevos melanocíticos acrales y evaluar su aplicabilidad en una población latinoamericana en Uruguay. Pacientes y métodos: Se trata de un estudio observacional, descriptivo y transversal realizado por 2 dermatólogos de 4 clínicas dermatológicas en Uruguay. Se incluyeron pacientes mayores de 18 años con nevos melanocíticos acrales. Las imágenes dermatoscópicas fueron captadas y analizadas de forma conjunta por 2 investigadores. Resultados: Un total de 158 nevos volares acrales en 80 pacientes fueron analizados. El patrón más frecuente fue el patrón paralelo del surco (51,3% de los nevos), seguido por el patrón en celosía (13,3%), el patrón homogéneo (12,7%), el patrón globular (9,5%), el patrón fibrilar (7%), el patrón retículo-globular (3,8%), y el patrón atípico (2,5%). No se observaron los patrones reticular y de transición en nuestra población. Conclusiones: El patrón paralelo del surco, seguido por los patrones en celosía y homogéneo, fueron los más frecuentes en nevos melanocíticos acrales en la población uruguaya. El patrón fibrilar se encuentra exclusivamente en las plantas de los pies. No se observaron nuevos patrones dermatoscópicos. Los patrones descritos en la literatura asiática y europea son aplicables a nuestra población (AU)

Background: Melanocytic nevi are frequently found on acral volar skin. Differentiation between nevi and melanoma is essential and sometimes difficult, although dermoscopy has enabled a more specific diagnosis of pigmented lesions. Dermoscopic patterns of lesions on acral volar skin have mostly been described in European and Asian populations. The Latin American population is heterogeneous, and particularly so in the case of Uruguayans, who largely descend from 3 distinct populations. Objective: To describe dermoscopic patterns of acral melanocytic nevi and evaluate their applicability in a Latin American population in Uruguay. Patients and Methods: This was an observational, descriptive, cross-sectional study conducted by 2 dermatologists from 4 dermatology clinics in Uruguay. Uruguayan patients older than 18 years with acral melanocytic nevi were included. Digital dermoscopic images were captured and jointly analyzed by 2 investigators. Results: A total of 158 acral volar nevi in 80 patients were analyzed. The most-prevalent pattern was the parallel furrow pattern (51.3% of nevi), followed by the latticelike pattern (13.3%), the homogeneous pattern (12.7%), the globular pattern (9.5%), the fibrillar pattern (7%), the globulostreaklike pattern (3.8%), and the nontypical pattern (2.5%). The reticular and transition patterns were not observed in our population. Conclusions: The parallel furrow pattern, followed by the latticelike and homogeneous patterns, was the most-prevalent pattern in acral melanocytic nevi in the Uruguayan population. The fibrillar pattern was found exclusively on the soles. No new dermoscopic patterns were observed. The patterns described in Asian and European literature apply to our population(AU)

Dermoscopic patterns of 158 acral melanocytic nevi in a Latin American population.

BACKGROUND: Melanocytic nevi are frequently found on acral volar skin. Differentiation between nevi and melanoma is essential and sometimes difficult, although dermoscopy has enabled a more specific diagnosis of pigmented lesions. Dermoscopic patterns of lesions on acral volar skin have mostly been described in European and Asian populations. The Latin American population is heterogeneous, and particularly so in the case of Uruguayans, who largely descend from 3 distinct populations. OBJECTIVE: To describe dermoscopic patterns of acral melanocytic nevi and evaluate their applicability in a Latin American population in Uruguay. PATIENTS AND METHODS: This was an observational, descriptive, cross-sectional study conducted by 2 dermatologists from 4 dermatology clinics in Uruguay. Uruguayan patients older than 18 years with acral melanocytic nevi were included. Digital dermoscopic images were captured and jointly analyzed by 2 investigators. RESULTS: A total of 158 acral volar nevi in 80 patients were analyzed. The most-prevalent pattern was the parallel furrow pattern (51.3% of nevi), followed by the latticelike pattern (13.3%), the homogeneous pattern (12.7%), the globular pattern (9.5%), the fibrillar pattern (7%), the globulostreaklike pattern (3.8%), and the nontypical pattern (2.5%). The reticular and transition patterns were not observed in our population. CONCLUSIONS: The parallel furrow pattern, followed by the latticelike and homogeneous patterns, was the most-prevalent pattern in acral melanocytic nevi in the Uruguayan population. The fibrillar pattern was found exclusively on the soles. No new dermoscopic patterns were observed. The patterns described in Asian and European literature apply to our population.

Clinical, dermoscopic and histopathologic features of genital and extragenital lichen sclerosus.

BACKGROUND: Little is currently known about the dermoscopic patterns of genital and extragenital lichen sclerosus (LS). In order to evaluate and compare the dermoscopic and histopathologic patterns of genital and extragenital lichen sclerosus, a retrospective analysis of clinical, dermoscopic and histopathologic features of genital and extragenital LS, collected between March 2010 and December 2011 at four dermatology clinics in Greece, Italy, Serbia and Uruguay was performed. OBSERVATIONS: A total of 29 lesions from 14 (mean age 62.8 years) and 12 (mean age 53.5 years) patients with genital and extragenital LS, respectively were analyzed. Mean duration of disease was 3.5 years for genital and 1.8 years for extragenital LS. White-yellowish structureless areas were seen in all cases of genital and extragenital LS; however linear vessels occurred at higher frequency in genital than in extragenital lesions (85.7% vs. 33.3%, respectively). Extragenital LS revealed two different time-related patterns: keratotic plugs were more prevalent in lesions with short duration (<2 years), whereas longer persisting lesions appeared atrophic and revealed fine chrysalis structures. CONCLUSIONS: Our morphologic study provides novel insights into the morphologic diversity of LS at different body sites and different stages of progression.

Cutaneous manifestations in 100 renal and reno-pancreatic recipients of Uruguay.

Uruguay is the second country of Latin America in prevalence of renal replacement therapies, including functioning kidney allografts. Long-term immunosuppressive therapy is essential for adequate graft function, but results in reduced immunosurveillance leading to an increased risk of complications such as infections and malignancies. A variety of cutaneous manifestations as well as an increase in non-melanoma skin cancers have been reported in this population. The objective of this study was to evaluate the frequency and clinical spectrum of cutaneous manifestations in renal and reno-pancreatic recipients in Uruguay. One hundred renal or reno-pancreatic recipients aged between 21- and 77-years-old were evaluated between September 2009 and September 2010. A total of 104 dermatoses were observed; 68% of the patients had at least one cutaneous manifestation. The most frequent dermatoses were cutaneous side effects due to immunosuppressive treatment (43.3%), followed by infections (27.9%), miscellaneous causes (22.1%), as well as malignant and premalignant lesions (6.7%). This is the first study evaluating dermatological complications in organ transplant recipients in our country. Most of the patients had at least one dermatological manifestation of immunosuppression, including a malignant or pre-malignant lesion, highlighting that this is a high-risk dermatological population. Cancer is one of the most important causes of death in recipients with functioning grafts. Its prevention is a major goal in the care of transplant recipients. Physicians in transplant units should be aware of the importance of dermatological screening and skin cancer surveillance.

CDKN2A mutations in melanoma families from Uruguay.

BACKGROUND: Familial melanoma, a cluster of several cases within a single family, accounts for approximately 10% of cases of melanoma. Hereditary melanoma is defined as two or more first-degree relatives having melanoma. A member of a melanoma-prone family has a 35-70-fold increased relative risk of developing a melanoma. Genetic susceptibility is linked to the major susceptibility genes CDKN2A and CDK4, and the minor susceptibility gene MC1R. OBJECTIVES: To determine the clinical and genetic characteristics of cutaneous melanoma in melanoma-prone families from Uruguay. METHODS: We studied 13 individuals from six melanoma-prone families living in Uruguay. Phenotype, familial and personal history were recorded. Molecular screening of CDKN2A and CDK4 was done by polymerase chain reaction-single strand conformational polymorphism analysis. The MC1R gene was sequenced. RESULTS: Mutations in CDKN2A were detected in five of six families: c.-34G>T, p.G101W and p.E88X. A novel germline mutation p.E88X, associated with hereditary melanoma in two unrelated families, is described. We hypothesize that a founder effect occurred probably in the Mediterranean region. No mutations in CDK4 were detected. Six different MC1R variants, all previously reported, were present in Uruguayan families. CONCLUSIONS: The overall rate of deleterious CDKN2A mutations in our familial melanoma pedigrees, even though the sample size is small, was considerably higher (83%) than the often quoted range.

Piodermitis a Staphylococcus aureusmeticilino resistente comunitario en elServicio de Dermatología del Hospitalde Clínicas de Uruguay / Community-adquired methicilin-resistant Staphylococcus aureus pyodermitis

El Staphylococcus aureus meticilin resistente (SAMR), es un conocido patógeno intrahospitalario que actualmente surge como una causa prominentede infecciones cutáneas adquiridas en la comunidad (SAMR.com). En el Uruguay en los últimos años se notificó la existencia de una nueva clona concaracterísticas genotípicas y fenotípicas particulares, que ha generado una alerta sanitaria a nivel nacional. En este estudio describimos la incidencia deSAMR.com y sus diversas presentaciones clínicas, en los pacientes que consultaron en la policlínica de la Cátedra de Dermatología del Hospital de Clínicasde la Facultad de Medicina de Montevideo-Uruguay, durante el período comprendido entre el 1 de julio y el 30 de septiembre de 2004. Incluimostreina y nueve pacientes con sospecha clínica de presentar SAMR-com. Se cultivó dicho germen en veintitrés. Las patologías implicadas con mayor frecuenciaen los pacientes que desarrollaron SAMR-com fueron eccemas, forunculosis, foliculitis, y úlceras de miembros inferiores (AU)

Methicilin-resistant Staphylococcus aureus, a well known inpatient pathogen, is nowadays an important cause of community acquired skin infections.A new genotipicaly and phenotypicaly peculiar clone that caused a sanitary alert was notified community acquired in Uruguay during last years. Herewithwe describe the incidence and clinical manifestations of Methicilin-resistant Staphylococcus aureus (MRSA.ca), from the patients that consultedat the Hospital de Clínicas Dermatology Departament during july 1st and september 30, 2004. We included 39 suspicious MRSA.ca patients, 23 ofwhom had positive bacteriological cultures. Most frequent pathologies that cultured MRSA.ca were eczema, forunulitis/forunulosis and lower limbswounds (AU)

Carcinoma de células de Merkel / Merkel cell carcinoma

El carcinoma de células de Merkel (CCM) es una neoplasia neuroendócrina infrecuente con alta mortalidad específica. Su diagnóstico se basa en la clínica,histopatología e inmunohistoquímica. Presentamos a una paciente de 83 años con tumoración de mejilla izquierda de 45 días de evolución. Condiagnóstico presuntivo de queratoacantoma se realizó exéresis y biopsia. La histolopatología sugiere y la inmunohistoquímica certifica el diagnósticode CCM. No se demostró invasión y se procedió a la resección quirúrgica. Dada la edad y la flacidez facial de la paciente, se eligió la M-Plastia doble porsu simpleza, solidez y escasa probabilidad de complicaciones postoperatorias (AU)

The Merkel cell carcinoma (MCC) is an infrequent neuroendocrine neoplasm with a high specific mortality rate. Its diagnosis is supported by the clinic,histopathology and immunohistochemistry. A 83 year old female patient who has had a tumor on her left cheek for 45 days is reported. With a presumptivekeratoacanthoma diagnosis, exeresis biopsy was performed. Histopathology and immunohistochemistry studies suggest MCC. No invasionwas found and surgical resection followed. Due to the patient’s age and facial flaccidness, double M-Plasty was chosen for its simplicity, reliability andminimal probability of postsurgical complications (AU)

Dermatoscopia en lesiones melanocíticas: propuesta de puntos críticos de corte de score dermatoscópico total para el diagnóstico oportuno de melanoma / Dermatoscopy in melanocytic lesions: critical cutting-points of total dermatoscopic score for diagnosing melanoma

La dermatoscopia ha demostrado elevar la capacidad diagnóstica en etapas tempranas de melanoma. Entre sus sistemas de cuantificación de riesgo, el score dermatoscópico total (TDS) es uno de los más usados. Su estrategia de validación consistió en aplicarlo en un vasto grupo de lesiones melanocíticas que incluyeron melanomas de fácil diagnóstico clínico con altos valores de TDS, por lo que el "punto de corte" resultó de alta exigencia, lo que explica la disminución del valor predictivo de la prueba negativa (VPPN) en lesiones clínicamente dudosas (LCD) entre melanoma "fino" y nevo con intensa actividad juncional. El objetivo del presente estudio fue estudiar "puntos de corte" de TDS aplicables a LCD que logren disminuir la proporción de falsos negativos. Material y método: de un total de 2.396 lesiones melanocíticas, 187 fueron resecadas y estudiadas. Algo más de la mitad se integró por nevos melanocíticos adquiridos o congénitos, lentigos actínicos y melanomas clínicamente evidentes, mientras que 92 correspondieron a LCD de melanoma, las que constituyeron nuestro grupo de estudio. En cada una se calculó el TDS según los criterios clásicos. La anatomía patológica permitió establecer diagnóstico en todos los casos y conformar 2 grupos, que fueron testados en cuanto a sexo, edad, fototipo, presencia ded síndromes familiares de múltiples nevos y de nevos atípicos, o ambos (SNM y SNA). Resultados: la anatomía patológica mostró 63 nevos melanocíticos (grupo A) y 29 melanomas (grupo B). No existieron diferencias significativas en cuanto a sexo, edad, fototipo o presencia de SNM o SNA. Con los valores de TDS se calcularon los parámetrros de exactitud y se elaboró una curva ROC a fin de determinar el "punto de corte" más apropiado, que para este grupo de lesiones resultó algo más bajo que el de Stolz, con 93,1 por ciento de sensibilidad, 85,7 por ciento de especificidad y 96,4 por ciento de VPPN. Conclusión: nuestros resultados muestran que para el caso de LCD el "punto de corte" propuesto logra un excelente VPPN sin afectación de los niveles de sensibilidad y especificidad. Pensamos que serán necesarias series más numerosas y estudios prospectivos para validar esta propuesta.

[Comparative study between alkaline phosphatase and gamma-glutamyltranspeptidase in the diagnosis of hepatic metastases]. / Etude comparative entre la phosphatase alcaline et la gamma-glutamyl-transpeptidase dans le diagnostic des métastases hépatiques.

Diagnostic values of alkaline phosphatases (AP) and gamma-glutamyl-transpeptidase (GGT) in hepatic metastases were compared in 48 patients with digestive carcinomas. The study was a prospective one conducted under blind conditions. The AP was less sensitive (0.50) than the GGT (0.86) but was more specific (0.96 as against 0.88). Diagnostic value of GGT (0.87) was therefore greater than of AP (0.75). Positive predictive value of AP was 0.70 and of GGT 0.57. The risk of detecting hepatic metastases was 9% if the AP was normal and 2% if the GGT was normal.