Infections in the era of immunobiologicals.

Immunobiologicals represent an innovative therapeutic option in dermatology. They are indicated in severe and refractory cases of different diseases when there is contraindication, intolerance, or failure of conventional systemic therapy and in cases with significant impairment of patient quality of life. The main immunobiologicals used in dermatology basically include inhibitors of tumor necrosis factor-alpha (anti-TNF), inhibitors of interleukin-12 and -23 (anti-IL12/23), inhibitors of interleukin-17 and its receptor (anti-IL17), inhibitors of interleukin-23 (anti-IL23), rituximab (anti-CD20 antibody), dupilumab (anti-IL4/IL13) and intravenous immunoglobulin. Their immunomodulatory action may be associated with an increase in the risk of infections in the short and long term, and each case must be assessed individually, according to the risk inherent to the drug, the patient general condition, and the need for precautions. This article will discuss the main risks of infection associated with the use of immunobiologicals, addressing the risk in immunocompetent and immunosuppressed patients, vaccination, fungal infections, tuberculosis, leprosy, and viral hepatitis, and how to manage the patient in the most diverse scenarios.

Development of a multivariate predictive model for dapsone adverse drug events in people with leprosy under standard WHO multidrug therapy.

BACKGROUND: The occurrence of adverse drug events (ADEs) during dapsone (DDS) treatment in patients with leprosy can constitute a significant barrier to the successful completion of the standardized therapeutic regimen for this disease. Well-known DDS-ADEs are hemolytic anemia, methemoglobinemia, hepatotoxicity, agranulocytosis, and hypersensitivity reactions. Identifying risk factors for ADEs before starting World Health Organization recommended standard multidrug therapy (WHO/MDT) can guide therapeutic planning for the patient. The objective of this study was to develop a predictive model for DDS-ADEs in patients with leprosy receiving standard WHO/MDT. METHODOLOGY: This is a case-control study that involved the review of medical records of adult (≥18 years) patients registered at a Leprosy Reference Center in Rio de Janeiro, Brazil. The cohort included individuals that received standard WHO/MDT between January 2000 to December 2021. A prediction nomogram was developed by means of multivariable logistic regression (LR) using variables. The Hosmer-Lemeshow test was used to determine the model fit. Odds ratios (ORs) and their respective 95% confidence intervals (CIs) were estimated. The predictive ability of the LRM was assessed by the area under the receiver operating characteristic curve (AUC). RESULTS: A total of 329 medical records were assessed, comprising 120 cases and 209 controls. Based on the final LRM analysis, female sex (OR = 3.61; 95% CI: 2.03-6.59), multibacillary classification (OR = 2.5; 95% CI: 1.39-4.66), and higher education level (completed primary education) (OR = 1.97; 95% CI: 1.14-3.47) were considered factors to predict ADEs that caused standard WHO/MDT discontinuation. The prediction model developed had an AUC of 0.7208, that is 72% capable of predicting DDS-ADEs. CONCLUSION: We propose a clinical model that could become a helpful tool for physicians in predicting ADEs in DDS-treated leprosy patients.

Severe form of lymphocutaneous sporotrichosis: a case report.

Sporotrichosis is the most frequent subcutaneous mycosis in Latin America. It is caused by species of the genus Sporothrix. Infection in humans occurs through the entry of the fungus into the skin. Zoonotic outbreaks involving cats in the transmission of the disease have been frequently reported. The lymphocutaneous form is the most commonly observed and the upper limbs are the most affected sites. We report a case of a 64-year-old healthy female patient with a lymphocutaneous form with rapid progression of lesions, which was refractory to initial treatment with itraconazole. Treatment with liposomal amphotericin B was performed with a satisfactory resolution, but aesthetic and functional sequelae in the left upper limb were installed.

Severe form of lymphocutaneous sporotrichosis: a case report

ABSTRACT Sporotrichosis is the most frequent subcutaneous mycosis in Latin America. It is caused by species of the genus Sporothrix. Infection in humans occurs through the entry of the fungus into the skin. Zoonotic outbreaks involving cats in the transmission of the disease have been frequently reported. The lymphocutaneous form is the most commonly observed and the upper limbs are the most affected sites. We report a case of a 64-year-old healthy female patient with a lymphocutaneous form with rapid progression of lesions, which was refractory to initial treatment with itraconazole. Treatment with liposomal amphotericin B was performed with a satisfactory resolution, but aesthetic and functional sequelae in the left upper limb were installed.

Necrose de parafinoma peniano após injeção de óleo mineral por profissional não médico / Penile paraffinoma necrosis after mineral oil injection applied by a non-medical professional

Parafinoma decorre da implantação de óleo mineral na pele, sendo caracterizado por reação inflamatória do tipo corpo estranho com período de latência variável. As lesões iniciais são nódulos endurecidos, que podem ulcerar, fistulizar ou necrosar. Esta técnica foi muito utilizada para fins estéticos no século XX, não sendo mais realizada por médicos. Contudo, ainda é empregada por profissionais não médicos ou pelos próprios pacientes, principalmente na região genital, para melhoria da prática sexual. Relata-se caso de implante de óleo mineral no pênis, realizado por profissional não médico para fins estéticos, que evoluiu com necrose após três anos.

Paraffinoma results from the implantation of mineral oil in the skin, being characterized by inflammatory reaction of foreign body type, with variable latency period. Initial lesions consist of hardened nodules, which can ulcerate, fistulate or necrose. This technique was widely used for aesthetic purposes in the 20th century, and is no longer performed by physicians. However, it is still used by non-medical professionals or by the patients themselves, mainly in the genital region, aimed at improving sexual activity. This paper reports a case of implantation of mineral oil in the penis, performed by a non-medical professional, for aesthetic purposes that evolved with necrosis after three years.

Coexistence of nail lichen planus and lichen planus pigmentosus

Abstract We describe a fifty-six-year old, Afro-descendent female patient showing dystrophy of her twenty nails and hyperchromic, asymptomatic macule on her face. Histopathological examination of the macule showed vacuolization of the basal layer, melanophages in the superficial dermis and lymphoplasmocytic inflammatory infiltrate. Nail biopsy revealed orthokeratotic hyperkeratosis and lichenoid inflammatory infiltrate. Lichen planus pigmentosus is an uncommon variety of lichen planus. It is characterized by typical hyperpigmented macules on the face and neck. Nail changes might be present in 10% of lichen planus cases, but no associations with lichen planus pigmentosus have been described. We report a case of lichen planus in twenty nails associated with lichen planus pigmentosus on the patient's face.

Scleredema of Buschke associated with difficult-to-control type 2 diabetes mellitus.

Scleredema of Buschke (SB) is a rare disorder of connective tissue characterized by diffuse non-pitting induration of the skin, mainly on the cervical, deltoid and dorsal regions. It is a cutaneous mucinosis of unknown etiology and is associated with bacterial or viral infections, hematological disorders and diabetes mellitus. Histopathological examination shows thickened dermis with wide collagen bundles separated by gaps that correspond to mucopolysaccharide deposits, visualized using special staining. Several treatments are reported in the literature without well-established results. We report a case of SB in a patient with type 2 diabetes mellitus.

Scleredema of Buschke associated with difficult-to-control type 2 diabetes mellitus / Escleredema de Buschke associado a diabetes mellitus tipo 2 de difícil controle

SUMMARY Scleredema of Buschke (SB) is a rare disorder of connective tissue characterized by diffuse non-pitting induration of the skin, mainly on the cervical, deltoid and dorsal regions. It is a cutaneous mucinosis of unknown etiology and is associated with bacterial or viral infections, hematological disorders and diabetes mellitus. Histopathological examination shows thickened dermis with wide collagen bundles separated by gaps that correspond to mucopolysaccharide deposits, visualized using special staining. Several treatments are reported in the literature without well-established results. We report a case of SB in a patient with type 2 diabetes mellitus.

RESUMO Escleredema de Buschke (EB) é doença rara do tecido conjuntivo caracterizada por endurecimento difuso e não depressível da pele, principalmente nas regiões cervical, deltoideanas e dorso. Enquadrado no grupo das mucinoses cutâneas, tem etiologia desconhecida e associação com: infecções bacterianas ou virais, alterações hematológicas e diabetes mellitus. O exame histopatológico evidencia derme espessada com fibras colágenas calibrosas separadas por fendas que correspondem a depósito de mucopolissacárides, observados por colorações especiais. Diversos tratamentos são relatados na literatura sem resultados bem definidos. Descrevemos caso de EB em paciente com diabetes mellitus tipo 2.

PARACOCCIDIOIDOMYCOSIS IN A RENAL TRANSPLANT RECIPIENT.

Paracoccidioidomycosis (PCM) is the most common endemic mycosis in Latin America. The etiological agents, which comprise two species, Paracoccidioides brasiliensis and P. lutzii, are thermodimorphic fungi that usually affect previously healthy adults. They primarily involve the lungs and then disseminate to other organs. Such mycosis is rare in organ transplant recipients; there have been only three cases reported in literature, until now. We report a case of PCM in a renal transplant recipient with an unusual dermatological presentation.

Coexistence of nail lichen planus and lichen planus pigmentosus.

We describe a fifty-six-year old, Afro-descendent female patient showing dystrophy of her twenty nails and hyperchromic, asymptomatic macule on her face. Histopathological examination of the macule showed vacuolization of the basal layer, melanophages in the superficial dermis and lymphoplasmocytic inflammatory infiltrate. Nail biopsy revealed orthokeratotic hyperkeratosis and lichenoid inflammatory infiltrate. Lichen planus pigmentosus is an uncommon variety of lichen planus. It is characterized by typical hyperpigmented macules on the face and neck. Nail changes might be present in 10% of lichen planus cases, but no associations with lichen planus pigmentosus have been described. We report a case of lichen planus in twenty nails associated with lichen planus pigmentosus on the patient's face.

PARACOCCIDIOIDOMYCOSIS IN A RENAL TRANSPLANT RECIPIENT

Paracoccidioidomycosis (PCM) is the most common endemic mycosis in Latin America. The etiological agents, which comprise two species, Paracoccidioides brasiliensis and P. lutzii, are thermodimorphic fungi that usually affect previously healthy adults. They primarily involve the lungs and then disseminate to other organs. Such mycosis is rare in organ transplant recipients; there have been only three cases reported in literature, until now. We report a case of PCM in a renal transplant recipient with an unusual dermatological presentation.

Poliarterite nodosa cutânea / Cutaneous polyarteritis nodosa

A poliarterite nodosa (PAN) cutânea é uma rara forma de vasculite, com curso crônico e recidivante, que envolve pequenas e médias artérias da derme e do tecido subcutâneo, sem o mesmo prognóstico da sua forma sistêmica. É caracterizada por nódulos subcutâneos, livedo reticular e ulcerações cutâneas. O diagnóstico é baseado no exame histopatológico e o tratamento é, na maioria das vezes, com corticosteroides, ciclofosfamida ou outro imunossupressor, embora não haja nenhuma terapia definitiva eficaz. Apresentamos o caso de uma paciente com PAN cutânea, com somente nódulos subcutâneos dolorosos.

Dermatite factícia: relato de um caso exuberante / Factitial dermatitis: report of an exuberant case

Dermatite factícia é uma condição na qual o paciente provoca lesões na própria pele, negando qualquer envolvimento no surgimento das mesmas. O aspecto da lesão é variável, com morfologia relacionada com o objeto utilizado. Representam com frequência um desafio diagnóstico devido à dificuldade de obtenção de informações verídicas na anamnese. Relata-se caso clínico com apresentação exuberante em paciente feminina de 45 anos, enfatizando a importância da abordagem multiprofissional nas dermatoses psicogênicas.

Lesão palpebral de lúpus discoide como manifestação única da doença / Eyelid?s discoid lupus lesion as the only manifestation of the disease

Lúpus eritematoso discoide é uma desordem autoimune benigna da pele e representa a forma clínica mais comum de lúpus eritematoso cutâneo. A apresentação do lúpus eritematoso discoide com acometimento palpebral exclusivo, como neste caso, é extremamente rara, o que dificulta o diagnóstico precoce da doença. O desconhecimento dessa apresentação de lúpus e o consequente retardo do seu diagnóstico podem contribuir com a progressão da doença e resultar em cicatrizes inestéticas, o que pode prejudicar a função palpebral.

Cutaneous leukocytoclastic vasculitis in the presence of methimazole therapy.

Treatment with antithyroid drugs may be accompanied by side effects. We present a patient diagnosed with Grave's Disease who developed extensive vasculitis in the lower limbs during methimazole use. After suspension of the methimazole and the introduction of prednisone in immunesupressor doses the cutaneous lesions started to involute.

Cutaneous leukocytoclastic vasculitis in the presence of methimazole therapy / Vasculite leucocitoclástica cutânea na vigência de terapêutica com metimazol

Treatment with antithyroid drugs may be accompanied by side effects. We present a patient diagnosed with Grave's Disease who developed extensive vasculitis in the lower limbs during methimazole use. After suspension of the methimazole and the introduction of prednisone in immunesupressor doses the cutaneous lesions started to involute.

A terapêutica com drogas antitireoidianas pode ser acompanhada de efeitos colaterais. Apresentamos um caso de paciente com diagnóstico de Doença de Graves que na vigência da terapêutica com metimazol desenvolveu um quadro extenso de vasculite de membros inferiores. A partir da suspensão do metimazol e da introdução de prednisona em doses imunossupressoras as lesões cutâneas entraram em involução.