Secondary syphilis presenting as Syphilide psoriasiforme: lessons from the older syphilology literature.

It is essential for health care providers to be familiared with the full spectrum of clinical presentations of syphilis. We present herein a case of syphilide psoriasiforme, an uncommon but well recognized clinical presentation of secondary syphilis. A 46-year-old HIV-infected female patient was referred to our attention with a presumptive diagnosis of palmoplantar psoriasis. On examination, there were exuberant pinkish-red papules and plaques covered with a thick silvery scale in the palms, flexor surfaces of the wrists, and the medial longitudinal arches of the feet. Serological and histopathological analyses uncovered the diagnosis of syphilis. Clinical remission was obtained after treatment. A detailed review of the literature on syphilide psoriasiforme, including descriptions from older syphilology textsis provided. The present case report emphasizes the need for clinicians to have a heightened awareness of the varied and unusual clinical phenotypes of syphilis.

Antiretroviral therapy-induced paradoxical worsening of previously healed Mycobacterium haemophilum cutaneous lesions in advanced HIV infection.

Mycobacterium haemophilum is a nontuberculous mycobacterium that causes localized or disseminated disease, mainly in immunocompromised hosts. We report the case of a 35-year-old HIV-infected woman who presented with several enlarging cutaneous lesions over the arms and legs. Histopathological examination revealed the diagnosis of a cutaneous mycobacterial disease. Mycobacterial analyses unveiled M. haemophilum infection. Six months after completion of a successful antimycobacterial treatment, she developed an immune reconstitution inflammatory syndrome (IRIS). This paradoxical relapse presented as tenderness, redness and swelling at the precise sites of the healed lesions and took place in the setting of significant recovery of the CD4 cell count (from 05 to 318 cells/mm 3 ). Microbiological analyses of these worsening lesions were negative, and they spontaneously remitted without the initiation of a novel antimycobacterial treatment cycle. M. haemophilum infection should always be considered as a cause of skin lesions in immunocompromised subjects. Physicians should be aware of the possibility of IRIS as a complication of successful antiretroviral therapy in HIV-infected patients with M. haemophilum infection.

Palate ulcer, uvular destruction and nasal septal perforation caused by Sporothrix brasiliensis in an HIV-infected patient.

Sporotrichosis is a human and animal disease caused by dimorphic pathogenic species of the genus Sporothrix. We report a dramatic presentation of Sporothrix brasiliensis infection, with destruction of the nasal septum, soft palate, and uvula of an HIV-infected woman. She was successfully treated with amphotericin B deoxycholate followed by itraconazole. Sporotrichosis remains a neglected opportunistic infection in patients with AIDS and awareness of this potentially fatal infection is of utmost importance.

Gastrointestinal CMV Disease and Tuberculosis in an AIDS Patient: Synergistic Interaction between Opportunistic Coinfections.

The AIDS pandemic has made diseases such as tuberculosis, CMV disease, and other opportunistic infections more prevalent; these diseases may even be found to be associated among themselves, and the natural history of each disease may present in an unusual manner. We report the case of a 41-year-old man with HIV (CD4 of 144 cells/dL) and HCV with hematochezia due to tuberculosis in the ileocecal valve and descending colon and CMV tissue invasive disease in the esophagus and descending colon. Coinfection among tuberculosis and cytomegalovirus in the gastrointestinal tract was described only once in a patient with a recent diagnosis of HIV that affected the distal ileum and ascending colon. We will discuss the peculiarities of the case and the behavior of the immune system in the face of simultaneous opportunistic infections. This is a challenging scenario that has scarce publications and is of great clinical importance.

Rapidly Progressive Disseminated Sporotrichosis as the First Presentation of HIV Infection in a Patient with a Very Low CD4 Cell Count.

Sporotrichosis is a human and animal disease caused by species of the Sporothrix schenckii complex. It is classically acquired through traumatic inoculation of fungal elements. Most frequently, sporotrichosis presents as a fixed cutaneous or as a lymphocutaneous form. A much smaller number of cases occur as cutaneous disseminated and disseminated forms. These cases require immediate diagnosis and management to reduce morbidity and mortality. We present the case of a 34-year-old male patient in whom the first presentation of HIV infection was a rapidly progressive sporotrichosis with multiple cutaneous lesions, a high fungal burden in tissues, and pulmonary involvement. He had an extremely low CD4 cell count (06/mm3). Treatment with amphotericin B deoxycholate led to complete clinical resolution. Sporotrichosis remains a neglected opportunistic infection among HIV-infected patients in Rio de Janeiro state, Brazil, and awareness of this potentially fatal infection is of utmost importance if treatment is not to be delayed and if potentially devastating complications are to be avoided.

Laryngeal paracoccidioidomycosis presenting as solitary true vocal fold disease.

Paracoccidioidomycosis (PCM) is a systemic granulomatous disease caused by Paracoccidioides brasiliensis or P. lutzii. It is a neglected tropical infectious disease that poses a major public health burden in endemic areas of Latin America. Mucosae of the upper digestive and respiratory tracts are commonly involved and many patients have disease at multiple mucosal sites, with or without lung involvement. Mucosal PCM presenting as solitary true vocal fold disease is relatively rare. We present the case of a 67-year-old Brazilian forest guard who presented with a 6-month history of hoarseness and globus pharyngeus due to a solitary left true vocal fold infiltration and vegetation diagnosed as PCM. Silent pulmonary disease was also present. A laryngoscopy video is offered as supplemental material to this report. He completely remitted after surgical removal and amphotericin B deoxycholate treatment.

An unusual case of bacillary angiomatosis in the oral cavity of an AIDS patient who had no concomitant tegumentary lesions - case report and review.

Bacillary angiomatosis (BA) is an angioproliferative disease of immunocompromised patients that usually presents as vascular tumors in the skin and subcutaneous tissues. It is caused by chronic infections with either Bartonella henselae or B. quintana. Oral cavity BA is exceedingly rare and even rarer without simultaneous cutaneous disease. We report herein the case of a 51-year-old HIV-infected man who presented severe odynophagia and an eroded lesion on the hard palate that progressed to an oronasal fistula. No cutaneous lesions were recorded. Doxycycline led to complete resolution. To the best of our knowledge, only six previous cases of oral BA without tegumentary disease have been previously reported and none of them progressed to fistula.

First Report of AIDS-Related Burkitt's Lymphoma Presenting as Bilateral Orbital Masses.

Burkitt's lymphoma (BL) is an aggressive B-cell non-Hodgkin's lymphoma and one of the fastest growing tumors in humans. It is an acquired immunodeficiency syndrome- (AIDS-) defining disease and occurs with relatively preserved CD4 cell counts. It rarely affects the orbital region in the setting of AIDS. We report unusual presentation of a fatal case of AIDS-associated BL in a 42-year-old female patient with severe CD4 cell depletion who presented with dramatic fast growing (within days) bilateral orbital masses leading to striking facial deformities. To the best of our knowledge, this is the first report of bilateral orbital involvement in AIDS-associated BL.

Prognostic angiogenic markers (endoglin, VEGF, CD31) and tumor cell proliferation (Ki67) for gastrointestinal stromal tumors.

AIM: To evaluate the correlation between the immunoexpression of angiogenic markers [CD31, CD105 and vascular endothelial growth factor (VEGF)], proliferative index (Ki67), and prognosis of patients with gastrointestinal stromal tumors (GIST). METHODS: This is a retrospective study of 54 GIST cases. Medical records were searched to obtain the GIST patients' demographic and clinical data, and paraffin-embedded blocks of tumor samples were retrieved from the hospital archives to conduct a new immunohistochemical evaluation. The tumor samples of GIST patients were subject to immunohistochemical evaluation for endoglin (CD105), CD31, VEGF, and Ki67 expression. The CD105 and CD31 intratumoral microvascular density (IMVD) was measured using automated analysis. We determined the correlation between the immunoexpression of CD105, CD31, VEGF, Ki67 and prognosis. In addition, we conducted a cutoff analysis using the receiver-operating characteristic curve. VEGF positivity was classified as either null/weak or strong. Ki67 was evaluated using a cutoff of 5% positive cells. The prognosis was classified as good (patient alive without recurrence) or poor (patient with recurrence/death). RESULTS: The distribution of tumor sites among the 54 analyzed samples was as follows: 27 (50%) in the stomach, 20 (37.1%) in the small intestine, 6 (11.1%) in the colon, and 1 (1.8%) in the esophagus. The size of the tumors ranged from 2 to 33 cm (median: 8 cm); in 12 cases (22.2%), the tumor was below 5 cm at the largest diameter, but in 42 cases (77.7%), the tumor was larger than 5 cm. The means of CD105 and CD31 were significantly higher in the group with poor prognosis (P < 0.001). The cut-off values of CD105 (> 1.2%) and CD31 (> 2.5%) in the receiver-operating characteristic curve were related to a poorer prognosis. Cases with a better prognosis showed significantly null/weak staining for VEGF (P < 0.001). Ki-67 expression of ≥ 5% was strongly correlated with a worse prognosis (P < 0.001). In the multivariate analysis, CD105 was the variable that most strongly correlated with prognosis. CONCLUSION: The IMVD cutoff values for the angiogenic markers CD105 and CD31, may be prognostic factors for GIST, in addition to VEGF and Ki67.

GIST: avaliações morfológica e imuno-histoquímica do prognóstico / GIST: morphological and immunohistochemical prognostic evaluation

INTRODUÇÃO: os tumores estromais gastrointestinais possuem amplo espectro biológico, variando desde lesões de comportamento benigno até aquelas de caráter maligno, capazes de ampla disseminação e frequentes metástases viscerais. Atualmente, o prognóstico está baseado num escore, denominado grau de risco. Entretanto, este sistema apresenta falhas, com tumores classificados como de riscos intermediário e baixo associados ao desenvolvimento de metástases. Desta forma, são necessários estudos que visem ao aprimoramento desse sistema de classificação, destacando-se nesse campo, nos últimos anos, o índice de proliferação celular que tem mostrado valor prognóstico na predição da agressividade tumoral. OBJETIVOS: analisar critérios morfológicos (tamanho macroscópico, topografia do tumor, índice mitótico, necrose, subtipo histológico), verificar o grau de risco e pesquisar a aplicabilidade dos marcadores imuno-histoquímicos (actina músculo-específico, proteína S-100, Ki67 e p16ink4a) como fatores prognósticos do tumor estromal gastrointestinal (GIST). RESULTADOS: a análise univariada mostrou significância com tumores maiores que 5 cm, número de mitoses maior que 5/50 CGA, presença de necrose, de grau de risco alto e índice de proliferação celular (Ki67) maior que 5 por cento com relação à redução da sobrevida global dos pacientes (p = 0,017; 0,01; 0,001; 0,016; < 0,001 respectivamente). Os outros fatores analisados (subtipo histológico, imunofenótipo e p16ink4a) não mostraram significância. CONCLUSÃO: o grau de risco, o tamanho tumoral, o índice mitótico e a presença de necrose corroboram evidências prévias da sua utilização, como fatores morfológicos prognósticos e o emprego do índice de proliferação celular (Ki67) associado ao grau de risco para melhor esclarecimento do comportamento biológico dos GIST.

INTRODUCTION: Gastrointestinal stromal tumors (GIST) have a wide biological spectrum, ranging from benign to malignant lesions, which are prone to wide spread and frequent visceral metastasis. Currently, the prognosis is based on a score system known as risk level. However, this system has some drawbacks. For instance, tumors classified as low or intermediate risk may be associated with the development of metastasis. Therefore, studies are required to improve this classification system and incorporate recent developments such as cellular proliferation index, which has shown prognostic value in the prediction of tumor aggressiveness. OBJECTIVES: To analyze morphological criteria (macroscopic size, tumor topography, mitotic index, necrosis, histological subtype), observe risk and investigate the usefulness of immunohistochemical markers (muscle-specific actin, S-100 protein, Ki67 and p16ink4a) as prognostic markers of GIST. RESULTS: Univariate analysis showed that a reduced global survival was significantly associated with tumor size greater than 5cm, mitotic index greater than 5/50 CGA, presence of necrosis, a high risk level, and a cellular proliferation index (Ki67) higher than 5 percent on the reduction of overall survivel of patients (p = 0.017, 0.010, 0.001, 0.016 and 0.0005, respectively). Other factors such as histological subtype, immunophenotype and p16ink4a were not significant. CONCLUSION: According to our data, risk level, tumor size, mitotic index and the presence of necrosis stood as morphological predictors of reduced survival, which underpins previous evidence of their application. The cellular proliferation marker Ki67 associated with risk level also proved to be a useful predictor of tumor aggressiveness.