RESUMO
Cutaneous adverse drug reactions collectively are delayed drug reactions such as morbilliform drug eruption and severe cutaneous adverse reactions (SCARs). Morbilliform drug eruption may wane over time, be the result of drug viral interactions, and be amenable to slow reintroduction or rechallenge, whereas SCARs are HLA class I restricted, T-cell-mediated reactions that demonstrate durable immunity and warrant lifelong avoidance. SCARs such as drug reaction with eosinophilia and systemic symptoms, Stevens-Johnson syndrome and toxic epidermal necrolysis, acute generalized exanthematous pustulosis, and generalized bullous fixed drug eruption often occur in the setting of multiple drugs dosed together. Collectively, they lead to significant morbidity, mortality, and drug safety concerns that could severely limit future treatment options. Currently, no single or combination of diagnostic tests for SCARs such as ex vivo or in vitro testing, in vivo (skin) testing, or other adjunctive tests such as HLA typing have 100% negative predictive value. In this "Controversies in Allergy Review" article, we review the current literature on delayed skin testing (patch and delayed prick/intradermal test) and critically assess the evidence base of its utility across different drugs and clinical phenotypes of delayed hypersensitivity reactions.
Assuntos
Antifúngicos , Toxidermias , Itraconazol , Humanos , Itraconazol/efeitos adversos , Itraconazol/uso terapêutico , Antifúngicos/efeitos adversos , Toxidermias/etiologia , Toxidermias/patologia , Toxidermias/diagnóstico , Masculino , Feminino , Pessoa de Meia-Idade , Exantema/induzido quimicamenteRESUMO
BACKGROUND: Cutaneous manifestations of drug-induced type IV reactions vary widely, with symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) being a less common presentation. Corticosteroids (CS), primarily known for their anti-inflammatory effects, rarely induce hypersensitivity reactions. OBJECTIVE: The aim of this case series is to report four cases of SDRIFE following systemic prednisolone therapy and to review existing CS classification proposals to better understand cross-reactivity of CS. PATIENTS/METHODS: Patients recruited at a German dermatology centre underwent allergologic evaluation including prick and patch testing with various CS. Positive cases underwent oral challenge testing with alternative agents. The classification systems of Coopman et al. and Baeck et al. were taken into account. DISCUSSION: Despite a paucity of literature, CS-induced type IV reactions do occur, including SDRIFE. Classification systems based on chemical structure provide insight into cross-reactivity patterns. Provocation tests with alternative CS highlight the complexity of managing CS hypersensitivity. CONCLUSION: SDRIFE may develop following systemic prednisolone therapy. Classification systems are helpful in understanding cross-reactivity and help in the selection of alternative preparations but are not always reliable. Individualised assessment is crucial for managing CS hypersensitivity, with consideration of alternative agents and emergency use of CS when necessary.
Assuntos
Toxidermias , Exantema , Prednisolona , Humanos , Feminino , Toxidermias/etiologia , Toxidermias/diagnóstico , Exantema/induzido quimicamente , Pessoa de Meia-Idade , Prednisolona/uso terapêutico , Prednisolona/administração & dosagem , Masculino , Adulto , Reações Cruzadas , Idoso , Testes do Emplastro , Glucocorticoides/uso terapêutico , Glucocorticoides/administração & dosagemAssuntos
Antifúngicos , Toxidermias , Itraconazol , Humanos , Itraconazol/efeitos adversos , Itraconazol/uso terapêutico , Antifúngicos/efeitos adversos , Toxidermias/etiologia , Toxidermias/patologia , Toxidermias/diagnóstico , Exantema/induzido quimicamente , Exantema/patologia , Masculino , Feminino , Pessoa de Meia-IdadeAssuntos
Antibacterianos , Humanos , Antibacterianos/efeitos adversos , Diagnóstico Diferencial , Testes do Emplastro , Feminino , Dermatite Alérgica de Contato/etiologia , Dermatite Alérgica de Contato/diagnóstico , Toxidermias/etiologia , Toxidermias/diagnóstico , Glucocorticoides/uso terapêutico , Masculino , Pessoa de Meia-Idade , RecidivaRESUMO
The zoonotic infectious disease mpox (previously known as monkeypox) is caused by the monkeypox virus (MPXV) from the Poxviridae family. Presently, mpox is receiving worldwide attention because of its emergence in countries that have never previously documented the illness, resulting in a public health emergency. MPXV is transmitted via human-to-human contact, and sexual contact is especially implicated in spread of the disease. Affected individuals experience fever, headache, malaise, and early lymphadenopathy, followed by a secondary mucotaneous rash. Oral ulcers and perioral papules may be the first evidence of the disease. Although there are numerous articles in medical publications documenting the cutaneous presentations of mpox, there is limited information in the dental literature regarding oral lesions. The objective of this article is to review the oral manifestations of mpox and strategies for management of the disease.
Assuntos
Mpox , Úlceras Orais , Humanos , Saúde PúblicaRESUMO
Roseola is a common viral exanthem of childhood, most frequently affecting infants and toddlers before age three. The syndrome is characterized by an abrupt onset of high fever, which, upon resolution, yields to a centrally located maculopapular rash that spreads peripherally. This report describes the case of an 18-month-old child whose fever and defervescence rash provide insight into the typical presentation and progression of this pervasive yet mostly benign condition.
RESUMO
The majority of viral rashes occurring during an antibiotic therapy are considered as a drug hypersensitivity reaction (DHR). Differentiating a viral rash versus a DHR is difficult or even impossible. In delayed DHRs the interplay between viruses and drugs is summarized according to the recent literature. The question is if the same reaction will again occur in case of drug re-exposure in absence of the concomitant viral infection because of persistent immune reactivity. Epstein Barr Virus (EBV) and Human Herpes virus 6 (HHV-6) models are analyzed in case of maculopapular exanthemas (MPEs) and drug reaction with eosinophilia and systemic symptoms (DRESS) over a course of drug therapy. MPEs are the most common skin manifestation during a viral infection and a concomitant drug therapy. In type IVb reactions to drugs a hapten/pro-hapten mechanism and a pharmacological interaction (p-i mechanism) are described as the 2 major ways to make T cells response functional. Rarely the altered repertoire model is involved. The Human Leukocyte Antigen (HLA) predisposition is an additional essential factor that can facilitate DHR. In MPEs rarely a DHR is confirmed by allergy testing. Severity and duration of MPEs, the presence of eosinophilia and systemic symptoms make more reliable the persistent nature of the reaction. Research on this topic is needed in order to provide the clinicians with instruments to decide when to suspect future reactions upon drug re-exposure even in the absence of a viral infection, because those patients should be investigated by a complete drug allergy work up.
RESUMO
Paciente varón que presentó exantema maculopapular, no pruriginoso, sin afectación palmoplantar, luego de recibir tratamiento con trimetoprim/sulfametoxazol por siete días debido a sintomatología gastrointestinal. Tras realizar historia clínica completa y con pruebas de cuarta generación se confirmó infección por VIH. Al quinto día de tratamiento antirretroviral presentó nuevas lesiones eritematosas con descamación gruesa, pruriginosas, edema facial y eosinofilia. Se realizó una biopsia de piel que reportó una dermatitis liquenoide, con espongiosis, degeneración vacuolar de la capa basal, queratinocitos necróticos e infiltrado de eosinófilos, características que favorecen la reacción por drogas. El tratamiento consistió en interrumpir la terapia combinada, uso de corticoides sistémicos, antihistamínicos y ya que, no se trató de un cuadro severo, se reinició el tratamiento antirretroviral sin complicaciones.
A male patient presented with a maculopapular, non-pruritic rash, without palmoplantar involvement, after receiving treatment with trimethoprim/sulfamethoxazole for seven days due to gastrointestinal symptoms. After taking a complete medical history and using fourth-generation tests confirmed HIV infection. On the fifth day of antiretroviral treatment, he presented new erythematous lesions with thick, pruritic scaling, facial edema and eosinophilia. A skin biopsy reported lichenoid dermatitis, with spongiosis, vacuolar degeneration of the basal layer, necrotic keratinocytes and eosinophil infiltrate, characteristics that favor drug reaction. The treatment consisted of interrupting the combined therapy, using systemic corticosteroids, antihistamines and since it was not a severe condition, antiretroviral treatment restarted without complications.
RESUMO
OBJECTIVE: Since the beginning of 2022, there has been an unusual outbreak of monkeypox in non-endemic countries that has alerted the international community. In Colombia, there are no recent studies on the epidemiology of patients in this new epidemic. Therefore, aim of this article was to establish the demographic and clinical characteristics of patients with monkeypox and their relationship with the frequency of hospitalization and other variables of clinical notification. METHODS: An observational, analytical, and cross-sectional study on monkeypox cases in Colombia between May and September 2022 was executed. Mann-Whitney U test was applied to contrast hypotheses between hospitalization and sociodemographic and quantitative notification variables; Fisher's exact test was used to contrast with the qualitative ones. RESULTS: Between May and September 2022, there were 1,260 cases of monkeypox reported in Colombia, 75% of the these were registered in Bogotá D.C. 99% (1,248) of those infected were male with a median age of 32.82% of the patients were from strata 2 and 3 (low to medium-low income). The source of infection was unknown in just over 80% of cases. Less than 1% belonged to ethnic groups. Only 3% required hospitalization. A significant statistically association was found between the frequency of hospitalization, being a woman (p=0.038), Afro-Colombian (p=0.024) and subsidized regime (p=0.009). No association of hospitalization was found with age, but it was found with the days from the onset of symptoms/rash to notification/diagnosis (p<0.05). CONCLUSIONS: Monkeypox cases are concentrated in the capital and other Andean departments of Colombia. Most of these progress without seriousness, without deaths. Men are the most affected population group. Women, afro-colombians and subsidized patients deserve special attention because they are more prone to hospitalization. Reducing the number of days from symptoms or rash to diagnosis and notification is key to avoiding serious cases.
OBJECTIVE: Desde inicio de 2022 se ha presentado un brote inusual de viruela símica en países no endémicos que ha alertado a la comunidad internacional. En Colombia, no existen trabajos recientes sobre la epidemiología de los pacientes en esta nueva epidemia. Por tanto, el objetivo del presente trabajo fue establecer las características epidemiológicas de pacientes con viruela símica y su relación con la frecuencia de hospitalización y otras variables de notificación clínica. METHODS: Se realizó un estudio observacional, analítico y transversal sobre los casos de viruela símica en Colombia entre mayo y septiembre de 2022. Se aplicó la prueba U de Mann-Whitney para el contraste de hipótesis entre hospitalización y variables sociodemográficas y de notificación cuantitativas; se usó la prueba exacta de Fisher para el contraste con las cualitativas. RESULTS: Entre mayo y septiembre de 2022 se presentaron 1.260 casos de viruela símica en Colombia, el 75% de estos se registraron en Bogotá D.C. El 99% (1.248) de los contagiados eran de sexo masculino, con mediana de 32 años. El 82% de los pacientes eran de estratos 2 y 3 (ingresos bajo a medio-bajo). La fuente de infección era desconocida en poco más del 80% de los casos. Menos del 1% pertenecían a grupos étnicos. Solo el 3% requirió hospitalización. Se encontró asociación estadística significativa entre frecuencia de hospitalización, ser mujer (p=0,038), afrocolombiano (p=0,024) y régimen subsidiado (p=0,009). No se encontró asociación de hospitalización con la edad, pero sí con los días desde el inicio de síntomas/exantema hasta la notificación/diagnóstico (p<0,05). CONCLUSIONS: Los casos de viruela símica se concentran en la capital y otros departamentos andinos de Colombia. La mayoría de estos cursan sin gravedad, sin fallecimientos. Los hombres son el grupo poblacional más afectado. Especial atención merecen las pacientes de sexo femenino, los afrocolombianos y los que se encuentran en régimen subsidiado por ser más proclives a hospitalización. Reducir el número de días desde los síntomas o exantema hasta el diagnóstico y notificación es clave para evitar casos graves.
Assuntos
Exantema , Mpox , Humanos , Masculino , Feminino , Colômbia/epidemiologia , Estudos Transversais , Espanha , Estudos RetrospectivosRESUMO
A considerable number of pediatric patients treated with beta-lactam (BL) antibiotics develop delayed onset of skin rashes during the course of treatment. Although the most frequent cause of these symptoms is infectious, many cases are labeled as allergic reactions to these drugs. BL allergy labels could have a negative impact, as they imply avoidance of this group of drugs and the use of second-line antibiotics, leading to a potential increase in adverse effects and the utilization of less effective therapies. This constitutes a major public health concern and economic burden, as the use of broad-spectrum antibiotics can result in multidrug-resistant organisms and prolonged hospital stays. Therefore, it is crucial to delabel patients during childhood to avoid false labeling in adult life. Although the label of BL allergy is among the most frequent causes of allergy referral, its management remains controversial, and new diagnostic perspectives are changing the paradigm of managing BL allergies in children. Traditionally, drug provocation testing (DPT) was exclusively performed in patients who had previously obtained negative results from skin tests (STs). However, the sensitivity of STs is low, and the role of in vitro testing in the pediatric population is not well defined. Recent studies have demonstrated the safety of direct DPT without prior ST or serum tests for pediatric patients who report a low-risk reaction to BLs, which is cost-effective. However, there is still a debate on the optimal allergic workup to be performed in children with a benign immediate reaction and the management of children with severe cutaneous adverse drug reactions. In this review, we will discuss the impact of the label of BL allergy and the role of the different tools currently available to efficiently address BL allergy delabeling in children.
RESUMO
Objectives: To investigate the characteristics of the skin microbiome in severe afatinib-induced skin toxicity. Methods: Body site-matched skin surface samples were collected from the lesions on seven flexural sites of one lung cancer (Patient 1) with serious systemic drug-related intertriginous and flexural exanthema (SDRIFE)-like toxicity induced by EGFR-TKI and three healthy age/sex matched controls for whole metagenomics sequencing analysis. Lung cancer Patient 1 and Patient 2 were prescribed minocycline and followed up. Results: In SDRIFE-like toxicities induced by afatinib, lesion microbiota richness (ACE and Chao1 index: p < 0.001) and diversity (Shannon's and Simpson's diversity indices: p < 0.01) were reduced. Similarly, the beta diversity analysis (R = 1, p = 0.002 for ANOSIM) showed that the apparent difference in the microbiota composition was statistically significant. The microbial taxa composition in the patient showed an increased abundance of pathogenic bacteria and a decreased abundance of commensal bacteria. LEfSe analysis identified strong bacterial pathogenicity in the patient, while healthy controls exhibited enrichment in several pathways that are beneficial for skin commensal bacteria and skin physiology, including key amino acid metabolism, energy/lipid/glycan biosynthesis/metabolism, and cofactors/vitamins biosynthesis. Ultimately, the patients experienced significant improvement with minocycline. Conclusion: Microbial dysbiosis is a characteristic of severe SDRIFE-like toxicity induced by afatinib.
RESUMO
Fundamentos: Desde inicio de 2022 se ha presentado un brote inusual de viruela símica en países no endémicos que ha alertado a la comunidad internacional. En Colombia, no existen trabajos recientes sobre la epidemiología de los pacientes en esta nueva epidemia. Por tanto, el objetivo del presente trabajo fue establecer las características epidemiológicas de pacientes con viruela símica y su relación con la frecuencia de hospitalización y otras variables de notificación clínica. Métodos:Se realizó un estudio observacional, analítico y transversal sobre los casos de viruela símica en Colombia entre mayo y septiembre de 2022. Se aplicó la prueba U de Mann-Whitney para el contraste de hipótesis entre hospitalización y variables sociodemográficas y de notificación cuantitativas; se usó la prueba exacta de Fisher para el contraste con las cualitativas. Resultados: Entre mayo y septiembre de 2022 se presentaron 1.260 casos de viruela símica en Colombia, el 75% de estos se registraron en Bogotá D.C. El 99% (1.248) de los contagiados eran de sexo masculino, con mediana de 32 años. El 82% de los pacientes eran de estratos 2 y 3 (ingresos bajo a medio-bajo). La fuente de infección era desconocida en poco más del 80% de los casos. Menos del 1% pertenecían a grupos étnicos. Solo el 3% requirió hospitalización. Se encontró asociación estadística significativa entre frecuencia de hospitalización, ser mujer (p=0,038), afrocolombiano (p=0,024) y régimen subsidiado (p=0,009). No se encontró asociación de hospitalización con la edad, pero sí con los días desde el inicio de síntomas/exantema hasta la notificación/diagnóstico (p<0,05). Conclusiones: Los casos de viruela símica se concentran en la capital y otros departamentos andinos de Colombia. La mayoría de estos cursan sin gravedad, sin fallecimientos. Los hombres son el grupo poblacional más afectado...(AU)
Background: Since the beginning of 2022, there has been an unusual outbreak of monkeypox in non-endemic countries that has alerted the international community. In Colombia, there are no recent studies on the epidemiology of patients in this new epidemic. Therefore, aim of this article was to establish the demographic and clinical characteristics of patients with monkeypox and their relationship with the frequency of hospitalization and other variables of clinical notification. Methods: An observational, analytical, and cross-sectional study on monkeypox cases in Colombia between May and September 2022 was executed. Mann-Whitney U test was applied to contrast hypotheses between hospitalization and sociodemographic and quantitative notification variables; Fishers exact test was used to contrast with the qualitative ones. Results: Between May and September 2022, there were 1,260 cases of monkeypox reported in Colombia, 75% of the these were registered in Bogotá D.C. 99% (1,248) of those infected were male with a median age of 32.82% of the patients were from strata 2 and 3 (low to medium-low income). The source of infection was unknown in just over 80% of cases. Less than 1% belonged to ethnic groups. Only 3% required hospitalization. A significant statistically association was found between the frequency of hospitalization, being a woman (p=0.038), Afro-Colombian (p=0.024) and subsidized regime (p=0.009). No association of hospitalization was found with age, but it was found with the days from the onset of symptoms/rash to notification/diagnosis (p<0.05). Conclusions: Monkeypox cases are concentrated in the capital and other Andean departments of Colombia. Most of these progress without seriousness, without deaths. Men are the most affected population group. Women, afro-colombians and subsidized patients deserve special attention because they are more prone to hospitalization...(AU)
Assuntos
Humanos , Masculino , Feminino , Adulto Jovem , Adulto , Hospitalização , Mpox/epidemiologia , Exantema , Zoonoses , Colômbia/epidemiologia , Saúde Pública , Estudos TransversaisRESUMO
Drug reaction with eosinophilia and systemic symptoms (DRESS syndrome) or drug-induced hypersensitivity syndrome (DIHS) is a severe skin reaction associated with general symptoms and mortality reaching up to 10% of cases. DRESS/DIHS is one of the few dermatological emergencies which need to be taken into consideration when dealing with a patient with acute exanthema and systemic symptoms like: fever, lymphadenopathy, muscle pain, hepatosplenomegaly, abnormal blood count results and systemic inflammation. The aim of this article is to summarize the literature finding regarding this dermatological emergency and present the case of a 42-year-old male suffering from DRESS syndrome as a consequence of sulfasalazine intake due to an inflammatory bowel disease, who was effectively treated with oral prednisolone and immediate drug withdrawal.
RESUMO
INTRODUCTION: Various cutaneous manifestations have been reported as symptoms of coronavirus disease 2019 (COVID-19), which may facilitate early clinical diagnosis and management. This study explored the incidence of cutaneous manifestations among hospitalised patients with COVID-19 and investigated its relationships with viral load, co-morbidities, and outcomes. METHODS: This retrospective study included adult patients admitted to a tertiary hospital for COVID-19 from July to September 2020. Clinical information, co-morbidities, viral load (cycle threshold [Ct] value), and outcomes were analysed. RESULTS: In total, 219 patients with confirmed COVID-19 were included. Twenty patients presented with new onset of rash. The incidence of new rash was 9.1% (95% confidence interval=6.25%-14.4%). The most common manifestations were maculopapular exanthem (n=6, 42.9%, median Ct value: 24.8), followed by livedo reticularis (n=4, 28.6%, median Ct value: 21.3), varicella-like lesions (n=2, 14.3%, median Ct value: 19.3), urticaria (n=1, 7.1%, median Ct value: 14.4), and acral chilblain and petechiae (n=1, 7.1%, median Ct value: 33.1). The median Ct values for patients with and without rash were 22.9 and 24.1, respectively (P=0.58). There were no significant differences in mortality or hospital stay between patients with and without rash. Patients with rash were more likely to display fever on admission (P<0.01). Regardless of cutaneous manifestations, patients with older age, hypertension, and chronic kidney disease stage ≥3 had significantly higher viral load and mortality (P<0.05). CONCLUSION: This study revealed no associations between cutaneous manifestation and viral load or clinical outcomes. Older patients with multiple co-morbidities have risks of high viral load and mortality; they should be closely monitored.
Assuntos
COVID-19 , Exantema , Adulto , Humanos , COVID-19/complicações , SARS-CoV-2 , Estudos de Coortes , Carga Viral , Estudos Retrospectivos , PrognósticoRESUMO
INTRODUCTION: Congenital Zika syndrome (CZS) is a recently described disease. Our main objective was to evaluate and monitor, over 3 years, the ophthalmoscopic findings in children exposed to zika virus (ZIKV) during gestation. METHODS: This prospective observational study was conducted in Rio de Janeiro, Brazil, between April 2016 and May 2019. We evaluated two groups with exanthema serving as a proxy for viremia: (i) children whose mothers had exanthema during pregnancy and (ii) children who had microcephaly without maternal exanthema during pregnancy. We performed indirect ophthalmoscopy at recruitment and every 6 months thereafter. We also tested the association between ocular findings with maternal exanthema, microcephaly, CZS and maternal infection confirmed by reverse transcriptase quantitative polymerase chain reaction and gender. RESULTS: Of the 72 children included, 16 (22.2%) had optic nerve and/or retinal lesions. All 16 had CZS and 15 (93.7%) had microcephaly (14 at birth and 1 postnatally). The child with postnatally acquired microcephaly was born to a mother without exanthema during pregnancy. Fifty-six (77.8%) of the 72 children were followed for a median time of 24 months and none exhibited differences between admission and follow-up examinations. After logistic regression, only microcephaly at birth was associated with eye abnormalities (odds ratio, 77.015; 95% confidence interval, 8.85-670.38; p < 0.001). CONCLUSION: We observed that there was no progression of the lesions over the follow-up period. We also showed that the eye findings were associated only with microcephaly at birth. Attention should be paid to all children born during a ZIKV epidemic, regardless of maternal exanthema and/or microcephaly at birth.
Assuntos
Exantema , Microcefalia , Infecção por Zika virus , Zika virus , Recém-Nascido , Feminino , Gravidez , Criança , Humanos , Zika virus/genética , Infecção por Zika virus/diagnóstico , Infecção por Zika virus/epidemiologia , Microcefalia/epidemiologia , Seguimentos , Brasil/epidemiologia , Exantema/etiologia , MãesRESUMO
The case of a 42-year-old female patient with pronounced itching and exanthema, mainly in the area of the trunk and lower limbs, is presented. Previously, the patient took antihistamines without effect, was treated for scabies, but the itching remained pronounced and led to rash and excoriations. From the anamnesis, it was found that the patient has a high level of stress. According to the Hospital Anxiety and Depression Scale, the anxiety of the patient reached 14 points, and depression 1 point. Functional (psychogenic) itching was suspected. Since the patient refused dermatologist consultation, therapy with the anxiolytic temgicoluril, topical antipruritic agents and nonpharmacological methods of treatment were recommended at the initial stage. The patient felt a significant relief of itching symptoms on the first day of anxiolytic usage, she withdrew topical antipruritic agents after 5 days of anxiolytic treatment, in 15 days she began to reduce the dose of temgicoluril, and at the end of the third week she stopped treatment with anxiolytic due to a significant positive effect. In three weeks, practically all elements of the rash, except for the largest wounds from scratching, disappeared. The peculiarity of the case is that functional itching was completely eliminated during anxiolytic therapy without other systemic medications, which emphasizes the importance of eliminating the component of stress and anxiety in the treatment of such patients.
RESUMO
Objective: Folliculitis is a skin infection and inflammation that develops in the hair follicles. While most cases of folliculitis are caused by bacterial infections, here is a case of folliculitis caused by the Candida fungi in an immunocompetent host. Case report: A 23-year-old non-diabetic immunocompetent female with recurrent vaginal candidiasis developed clusters of erythematous, pruritic papules in the pubic area. Upon evaluation, the clusters were determined to be folliculitis. Risk factors for folliculitis included shaving of the pubic area, hot tub use, and wearing of tight, restrictive clothing. Cultures and skin samples of the folliculitis demonstrated Candida albicans. The patient was subsequently and successfully treated with clotrimazole solution and cream. There was no recurrence of the folliculitis upon her 3-month follow-up appointment. Conclusion: Candida folliculitis is a rare condition in non-diabetic patients. The patient's history, risk factors and immune status assessment, and physical examination with proper diagnostic testing, are crucial steps in attaining the correct diagnosis.