Yeasts of the genital region of patients attending the dermatology service at Hospital São Paulo, Brazil / Levaduras de la región genital en pacientes que acuden al servicio de dermatología en el Hospital São Paulo, Brasil

Background. The knowledge of the diversity of yeasts that make up the skin microbiota of human beings is essential for the efficient monitoring of infections to which a person may be predisposed. Aims. This study identified yeasts comprising the genital skin microbiota of patients attending the Dermatology Service at the Hospital São Paulo-UNIFESP, Brazil. Methods. Samples were collected from the genital region of each patient and cultured on Sabouraud dextrose agar. Individual colonies were carefully transferred to tubes daily. Yeasts were identified based on classical methodologies and confirmed using a commercial kit. Results. Eighty-three patients were included in the study. Approximately 80% were women and 20% were men. The average age was 55 years. Hypertension, diabetes, kidney transplant and AIDS were the main underlying diseases reported by the patients. The most prevalent yeasts were Candida parapsilosis (36.1%), Rhodotorula mucilaginosa (9.2%), Rhodotorula glutinis (8.3%), Candida tropicalis (5.5%) and Trichosporon inkin (1.8%). Approximately 78% of the isolates were obtained in pure cultures. Trichosporon inkin was isolated only from women, in contrast to literature describing a high prevalence in males. Conclusions. Our results suggest that Candida albicans is not the main yeast found on genital skin as previously thought, and opportunistic pathogens such as C. parapsilosis, C. tropicalis, Rhodotorula spp. and T. inkin make up the genital skin microbiota, representing a risk for infection in immunocompromised subjects. These results also indicate that women are carriers of T. inkin, the etiological agent of white piedra and trichosporonosis (AU)

Antecedentes. El conocimiento de la diversidad de las levaduras que conforman la microbiota de la piel de los seres humanos es fundamental para un eficaz seguimiento de las infecciones. Objetivos. En este estudio se identificaron las levaduras que componían la microbiota de la piel de los genitales de pacientes que acudieron al Servicio de Dermatología del Hospital São Paulo - Unifesp, Brasil. Métodos. Se recogieron muestras de la región genital de cada paciente y se cultivaron en agar dextrosa Sabouraud. Las colonias individuales se transfirieron cuidadosamente a tubos. La identificación de las levaduras se basó en metodologías clásicas y se confirmó utilizando un kit comercial. Resultados. Ochenta y tres pacientes fueron incluidos en el estudio. Aproximadamente el 80% eran mujeres y el 20% eran hombres. La edad promedio fue de 55 años. La hipertensión, la diabetes, el trasplante renal y el sida fueron las principales enfermedades subyacentes de los pacientes. Las levaduras más frecuentes fueron Candida parapsilosis (36,1%), Rhodotorula mucilaginosa (9,2%), Rhodotorula glutinis (8,3%), Candida tropicalis (5,5%) y Trichosporon inkin (1,8%). Aproximadamente el 78% de los aislamientos crecieron en cultivo puro. Trichosporon inkin fue aislado únicamente en mujeres, en contra de la literatura que describe una alta prevalencia en los hombres. Conclusiones. Nuestros resultados sugieren que Candida albicans no es la principal levadura que se encuentra en la piel de los genitales, como se pensaba, y los agentes patógenos oportunistas C. parapsilosis, C. tropicalis, Rhodotorula spp. y T. inkin conforman la microflora de la piel genital, lo que representa un riesgo inminente de infección para los pacientes inmunocomprometidos. Estos resultados también indican que las mujeres son portadoras del agente etiológico de la piedra blanca y de la tricosporonosis, T. inkin (AU)

Erythema leprosum--after treatment of Lepromatous Leprosy.

Leprosy is usually well-controlled by multidrug therapy (MDT). However, in case of noncompliance or leprosy reactions, it may present a therapeutically challenge. A 33-year-old Brazilian woman with lepromatous leprosy was treated with MDT for one year, but then discontinued therapy because she wanted to have children. Eight weeks after stopping her medications, she developed a severe and recalcitrant erythema (nodosum) leprosum (ENL) which presented histologically with thrombosed small veins and neutrophilic inflammation in fat septa, but without arteritis. During her pregnancy and ensuing lactation period, glucocorticoids were the only suitable drug. With the use of the shortened WHO/MDT regimen (one year vs. two years of treatment), ENL will probably be seen more often after the end of leprosy therapy. It needs to be rapidly recognized and treated to avoid damage to eyes or kidneys.

Onychomycosis in São Paulo, Brazil.

Onychomycosis is a fungal infection of the nails with broad aetiological scope, and it represents 18-40% of all onychopathies and 39% of all superficial mycotic infections. From July 1996 to December 1999, samples of nails were collected from 588 patients with presumptive diagnosis of onychomycosis at the Dermatology and Mycology Divisions EPM\UNIFESP, Brazil, and the diagnosis was confirmed in 247 of these cases. The most common pathogens isolated in this study were yeasts in 52% of positive cultures (Candida albicans 18.3%, Candida parapsilosis 13.8%, other species of Candida 15.4% and other yeasts 4.6%), followed by dermatophytes in 40.6% of positive cultures (the most commonly isolated organisms were Trichophyton rubrum in 33.2%, followed by Trichophyton mentagrophytes in 6.3% and others 1.2%). Non-dermatophyte moulds were isolated in 7.4% of positive cultures (Fusarium spp. 4.5%, Nattrassia mangiferae 2.3% and Aspergillus spp. 0.6%). Distal and lateral subungual onychomycosis (DLSO) was the commonest clinical pattern 44.6% followed by free edge onycholysis (FEO) 38.8% and others. In conclusion, this study demonstrated that T. rubrum is the main agent causing onychomycosis in toenails, and species of genus Candida were the main agents isolated in fingernail onychomycosis in our region.

Detection of Mycobacterium leprae infection in wild nine-banded armadillos (Dasypus novemcinctus) using the rapid ML Flow test.

Mycobaterium leprae infection was investigated in armadillos from the State of Espírito Santo, Brazil. The ML Flow test was performed on 37 nine-banded armadillos and positive results were found in 11 (29.7%). The ML Flow test may be used to identify possible sources of Mycobaterium leprae among wild armadillos.

Detection of Mycobacterium leprae infection in wild nine-banded armadillos (Dasypus novemcinctus) using the rapid ML Flow test

Mycobaterium leprae infection was investigated in armadillos from the State of Espírito Santo, Brazil. The ML Flow test was performed on 37 nine-banded armadillos and positive results were found in 11 (29.7 percent). The ML Flow test may be used to identify possible sources of Mycobaterium leprae among wild armadillos.

Tem sido pesquisado infecção pelo Mycobaterium leprae em tatus provenientes do estado do Espírito Santo-Brasil. O teste rápido ML Flow, foi realizado em 37 tatus selvagens, tendo sido positivo em 11 (29,7 por cento). O teste de ML Flow pode ser utilizado para identificar possíveis fontes de Mycobaterium leprae em tatus selvagens.

Leprosy situation in Brazil.

We present the situation of leprosy in Brazil, reporting about epidemiology, clinical criteria for classification, multidrugtherapy and special situations, as co-infection. This material was presented in the 79th Annual Meeting of Japanese Hansen's Disease Association in May 2006, during a discussion about the Japanese Guidelines for leprosy treatment.

Limitations of DNA sequencing for diagnosis of a mixed infection by two fungi, Phaeoacremonium venezuelense and a Plectophomella sp., in a transplant recipient.

We describe a rare case of a subcutaneous infection by both Phaeoacremonium venezuelense and Plectophomella sp. in a Brazilian male. Sequencing of a beta-tubulin gene fragment allowed us to confirm the identification of the former. However, a similar procedure of sequencing rRNA gene fragments was not useful for the identification of the latter fungus.

Dermatophytosis on the eyelid caused by Microsporum gypseum.

We report a case of tinea on the eyelid in a woman with psoriasis. Due to the history of psoriasis and clinical aspect of the lesion the diagnosis of psoriasis was suggested in the first place; however, laboratory examination revealed Microsporum gypseum. The patient was treated with oral itraconazole resulting in clinical and mycological cure. We emphasize the uncommon location of tinea caused by M. gypseum and the importance of searching for fungal infection on scaly lesions.

False positive reaction of the immunohistochemistry technique using anti-BCG polyclonal antibodies to identify Mycobacterium leprae in wild nine-banded armadillos.

The authors studied 66 wild nine-banded armadillos from Brazil. The ear samples were collected and Ziehl-Neelsen or Fite-Faraco stains were performed, as well as immunostaining using polyclonal BCG antibody, to avaluate the presence of the Mycobacterium leprae. The AFB were not detected by the Ziehl-Neelsen or Fite-Faraco staining, neither immunoexpression of the BCG marker. However, many normal structures from the ears of the nine-banded armadillos, such as condrocytes, condroblasts, fibroblasts and endothelial cells, and Gram positive bacteria cocci, showed false positive reaction by the BCG marker. The authors discuss the use of the immunohistochemical studies with the polyclonal BCG antibody to identify M. leprae antigens in wild armadillos.

Epidemiology of Kaposi's sarcoma in patients with acquired immunodeficiency syndrome in São Paulo, Brazil.

BACKGROUND: Kaposi's sarcoma (KS) is the most frequent neoplasm in patients with acquired immunodeficiency syndrome (AIDS). Although many studies on KS epidemiology have been performed in other countries, few have been carried out in Brazil despite the high incidence of AIDS. METHODS: One hundred and seven KS patients seen in São Paulo, Brazil, between August 1995 and November 1998 were studied. The patients were followed for 1 year with assessment of the immunologic status, improvement of the lesions, treatment, and causes of death at the end of this period. RESULTS: KS occurred mainly in men (94.4%) with a mean age of 37 years, and 25.2% of these patients were found to be human immunodeficiency virus (HIV) seropositive through KS. HIV was acquired mainly through homosexual contact. The patients presented an average of 15.9 KS lesions at the first visit and the mean duration of KS lesions before the first visit was 15.5 months. The clinical presentation was predominantly papules and plaques, and 33.6% presented with mucosal and/or visceral disease. KS affected mainly the lower limbs. The mean time since the diagnosis of HIV infection was 42.4 months. The CD4+ cell count was lower than 200 cell/mm(3) in 60.8% of patients, but patients with a complete response showed an improvement in immune status after 1 year. Patients who did not show progression received a protease inhibitor as part of highly active antiretroviral therapy (HAART). Patients treated exclusively with HAART presented a complete response (61.6%), partial response (23%) or progression (15.4%) of KS. CONCLUSIONS: An improvement in immune status and the use of HAART were the most important prognostic features.

High expression of myeloid-related proteins 8 and 14 characterizes an inflammatorily active but ineffective response of macrophages during leprosy.

Macrophages are decisive cells for the course of leprosy as they phagocytose Mycobacterium leprae and have the potential to influence the specific immune response. Expression and release of the myeloid-related protein (MRP) 8 and MRP14 (S100A8 and S100A9) characterize a proinflammatory subtype of macrophage that is prominent in, for example, murine infection with lack of a T helper 1 cell response and in certain highly active chronic inflammations of mice and humans. We investigated cutaneous biopsies of the different forms of leprosy (41 untreated patients) including leprosy reaction type 1 (reversal reaction) and type 2 (erythema nodosum leprosum) (n = 18) for expression of MRP8 and MRP14 by subtypes of macrophages. Concomitantly we determined serum levels of MRP8 and MRP14 by sandwich enzyme-linked immunosorbent assay. Expression of MRP8 and MRP14 by CD68-positive macrophages was low in tuberculoid leprosy and rose significantly in borderline tuberculoid leprosy and especially in multibacillary forms, there being expressed by mycobacteria-loaded foam cells. A significant rise of MRP8 and MRP14 expression also occurred in lepra reactions compared to the corresponding non-reactional forms. In type 2 reactions this additional increase was associated with a significant elevation of serum levels. In type 1 it was associated with expression of MRP8 and MRP14 by epitheloid and giant cells, which so far were considered not to express both proteins. In conclusion, we present evidence that the two prominent proteins MRP8 and MRP14 can be re-expressed in vivo by tissue macrophages in chronic infection, that their increased expression is characteristic for a macrophage subtype associated with high inflammatory but low antimycobacterial activity in the absence of a T helper 1 response, and that their significant rise in serum during erythema nodosum leprosum bears diagnostic and pathophysiological relevance.

High expression of myeloid-related proteins 8 and 14 characterizes an inflammatory active but ineffective response of macrophages during leprosy

Macrophages are decisive cells for the course of leprosy as they phagocytose Mycobacterium leprae and have the potential to influence the specific immune response. Expression and release of the myeloid-related protein (MRP) 8 and MRP14 (S100A8 and S100A9) characterize a proinflammatory subtype of macrophage that is prominent in, for example, murine infection with lack of a T helper 1 cell response and in certain highly active chronic inflammations of mice and humans. We investigated cutaneous biopsies of the different forms of leprosy (41 untreated patients) including leprosy reaction type 1 (reversal reaction) and type 2 (erythema nodosum leprosum) (n=18) for expression of MRP8 and MRP14 by subtupes of macrophages. Concomitantly we determined serum levels of MRP8 and MRP14 by sandwich enzyme-linked immunosorbent assay. Expression of MRP8 and MRP14 by CD68-positive macrophages was low in tuberculoid leprosy and rose significantly in borderline tuberculoid leprosy and especially in multibacillary forms, there being expressed by mycobacteria-loaded foam cells. A significant rise of MRP8 and MRP14 expression also occurred in lepra reactions compared to the corresponding non-reactional forms. In type 2 reactions this additional increased was associated with a significant elevation of serum levels. In type 1 it was associated with expression of MRP8 and MRP14 by epitheloid and giant cells, which so far were considered not to express both proteins. In conclusion, we present evidence taht the two prominent proteins MRP8 and MRP14 can be re-expressed in vivo by tissue macrophages in chronic infection, that their increased expression is characteristic for a macrophage subtype associated with high inflammatory but low antimycobacterial activity in the absence of a T helper 1 response, and that their significant rise in serum during erythema nodosum leprosum bears diagnostic and pathophysiological relevance.

Comparison between anti-PGL-I serology and Mitsuda reaction: clinical reading, microscopic findings and immunohistochemical analysis.

The lepromin test, serum IgM antibodies against Mycobacterium leprae and in situ observations of T cell subsets in biopsies of Mitsuda reaction using monoclonal antibodies were performed on 44 untreated leprosy patients belonging to various classifications of the disease. The Mitsuda reaction was accessed clinically and histologically after 28 days. Clinical reading and histological analysis of Mitsuda reaction showed good agreement. The high positivity in clinical reading correlated with compact granulomas in histology. There is a graduation of Mitsuda reaction that follows the immunological spectrum of the disease. The histological study of Mitsuda reaction is valuable to confirm the immunological condition in doubtful clinical reaction. Anti-PGL-I IgM levels correlated with disease classification, increasing from the tuberculoid towards the lepromatous pole of the disease spectrum. There was an inverse correlation between serum IgM antibody levels and clinical and histological reading of Mitsuda reaction. There were no statistical difference in quantities and distribution of CD4+ and CD8+ T cells in all Mitsuda reactions. The pattern of cellular content of Mitsuda reaction could not be related to the T cells.

Zosteriform connective tissue nevus: a case report.

Because of its distinctive clinical features and histopathological characteristics, zosteriform connective tissue nevus is considered a separate entity from other connective tissue nevi. Only two cases have previously been reported in the worldwide dermatological literature. Here we report a zosteriform connective tissue nevus in a 3-year-old boy with similar clinical presentation.

Lymphoscintigraphic analysis in chromoblastomycosis.

BACKGROUND: One of the main complications of chromoblastomycosis is lymphedema. The purpose of this study was to evaluate the lymphatic system of the limbs of patients with chromoblastomycosis using lymphoscintigraphy. It is a reliable, objective and noninvasive means of supporting the diagnosis of lymphedema. METHODS: Lymphoscintigraphy was performed in seven patients with chromoblastomycosis, six with lesions in the lower limb and one in the upper limb. Tc-99 m dextran was injected into the interdigital spaces of the upper or lower extremities. The qualitative parameters analyzed were the visibilization of the lymph vessels and the lymph nodes, dermal backflow, and existence of collateral vessels. All patients were treated with the association of itraconazole and cryotherapy with liquid nitrogen. RESULTS: Three out of the 14 extremities examined had lymphedema clinically, and the lymphoscintigraphy showed abnormalities in the qualitative parameters; whereas these parameters were normal in the extremities without lymphedema. During the treatment of chromoblastomycosis, a second lymphoscintigraphy exam was performed on 10 limbs and did not show any improvement of the previous lymphoscintigraphic alterations. CONCLUSIONS: The qualitative lymphoscintigraphy was a reliable method to show the morphology of the lymph vessels and confirm objectively the diagnosis of lymphedema secondary to chromoblastomycosis. The association of oral itraconazole and cryotherapy did not modify the lymphatic alterations in chromoblastomycosis.

Lepra leucomelanodérmica / Leukomelanodermic leprosy

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