Extensive mycetoma in forearm, chest and neck due to Nocardia mexicana.

INTRODUCTION: Mycetoma is a chronic granulomatous inflammatory disease of the subcutaneous tissue, which affects deep structures and bone. Most cases of actinomycetoma are caused by members of the genus Nocardia. CASE PRESENTATION: Here we report the case of a 43-year-old male who presented a disseminated mycetoma on the forearm, chest and neck, characterized by enlarged and erythematous lesions through which seropurulent material drains, and numerous atrophic scars. Molecular identification was performed by 16S gene amplification and sequencing. Nocardia mexicana was identified with 100% identity. Trimethoprim-sulfamethoxazole, diaminodiphenyl sulfone and amikacin was a successful treatment after 6 months. CONCLUSIONS: Nocardia mexicana is a rare organism that causes mycetoma. We report a case of extensive mycetoma on the forearm with spread to the neck and thorax associated with manipulation of the mouth of a calf.

Spontaneous radial nerve palsy with hourglass-like constriction.

Hourglass-like constriction (HLC) is an uncommon spontaneous mononeuropathy that is typically characterised by a sudden onset of pain followed by palsy, affecting branches of the radial (posterior interosseous nerve) and median nerves (anterior interosseous nerve). HLC of the radial nerve (RN) is rare, with only a few reported cases. Here, we report a case of a man who presented with acute wrist and finger drop due to the HLC of the RN. Surgery was recommended 5 months after clinical observation, when the lesion was resected and primarily repaired, resulting in satisfactory recovery. There is still much that remains unknown about HLC, especially for RN. The current understanding points out an inflammatory disease that should be treated conservatively for 3-7 months. The surgical technique depends mostly on the severity and extent of constriction; however, considering only RN constrictions, primary repair by neurorrhaphy or nerve grafts resulted in better functional outcomes.

Durometry as an alternative tool to the modified Rodnan's skin score in the assessment of diffuse systemic sclerosis patients: a cross-sectional study.

BACKGROUND: The reproducibility and reliability of the modified Rodnan's Skin Score (mRSS) are debated due to investigator-related subjectivity. Here, we evaluate if durometry correlates with mRSS in patients with diffuse systemic sclerosis (SSc). METHODS: This cross-sectional study was conducted from December 2018 to June 2019, including 58 diffuse SSc patients. Two certified researchers, blind to each other's scores, performed the mRSS, followed by durometry at 17 predefined skin sites. For durometry and mRSS, individual scores per skin site were registered. Durometry and mRSS results measured by each researcher, as well as scores from different researchers, were compared. Skin thickness measurements from forearm skin biopsies were available in a subset of the patients, for comparisons. Statistical analyses included Cohen's Kappa Coefficient, Intraclass Correlation Coefficient, Kendall's Coefficient and Spearman's test. RESULTS: Mean (standard deviation, SD) patient age was 44.8 (12.9) years, and 88% were female. Inter-rater agreement varied from 0.88 to 0.99 (Intraclass correlation coefficient) for durometry, and 0.54 to 0.79 (Cohen's Kappa coefficient) for mRSS, according to the specific evaluated sites. When data were compared with skin thickness assessed in forearm biopsies, durometry correlated better with skin thickness than mRSS. CONCLUSION: Durometry may be considered as an alternative method to quantify skin involvement in patients with diffuse SSc. The strong inter-rater agreement suggests that the method may be useful for the assessment of patients by multiple researchers, as in clinical trials.

Case for diagnosis. Erythematous and pruritic papules on forearms.

Gamasoidosis is a poorly known and underdiagnosed mite infestation. It is characterized by the presence of erythematous and flattened papules that are quite pruritic, and can affect any region of the body, with preference for areas of folds. This article reports a case of the disease caused by mites of the species Dermanyssus gallinae. Increasingly, the agents that cause this disease are found in urban environments, increasing the incidence of people affected by the disease. This dermatosis has a self-limiting clinical picture and the treatment is done with the use of topical corticosteroids and oral antihistamines.

Case for diagnosis. Erythematous and pruritic papules on forearms

Abstract Gamasoidosis is a poorly known and underdiagnosed mite infestation. It is characterized by the presence of erythematous and flattened papules that are quite pruritic, and can affect any region of the body, with preference for areas of folds. This article reports a case of the disease caused by mites of the species Dermanyssus gallinae. Increasingly, the agents that cause this disease are found in urban environments, increasing the incidence of people affected by the disease. This dermatosis has a self-limiting clinical picture and the treatment is done with the use of topical corticosteroids and oral antihistamines.

Tumores de células gigantes en el antebrazo / Tumors of giant cells in the forearm

Se presentan los casos clínicos de 2 pacientes atendidos en la consulta de Ortopedia del Hospital General Docente Dr Juan Bruno Zayas Alfonso de Santiago de Cuba. Uno había sido operado de un tumor de células gigantes en el tercio proximal del radio izquierdo hacía 3 años, con evolución satisfactoria hasta que comenzó a presentar aumento de volumen y dolor en el tercio distal de dicho radio, que limitaba la flexoextensión de la muñeca; el otro había sufrido un traumatismo en el tercio distal del antebrazo izquierdo y presentaba aumento de volumen entre los límites de la cara dorsal y ventral del antebrazo y la muñeca. Se realizó la exéresis de los tumores, con resección en bloque y fijación externa con injerto de hueso del banco destinado a ello en esta provincia. Ambos egresaron sin complicaciones y se indicó seguimiento por ortopedia y oncología.

The case reports of 2 patients assisted in the out-patient Orthopedics Deparment of Dr Juan Bruno Zayas Alfonso Teaching General Hospital in Santiago de Cuba are presented. One had been surgically treated 3 years ago due to a giant cells tumor in the proximal third of the left radius, with a satisfactory clinical course until it began to present volume increase and pain in the distal third of his radio that limited the wrist's flexoextension; the other patient had suffered a traumatism in the distal third of the left forearm and it presented increase of volume between the egdes of the dorsal and ventral sides of the forearm and the wrist. The exeresis to the tumors, with resection in block and external fixation with bank bone implants dedicated to this in the province were carried out. Both patients were discharged without complications and Orthopedics and Oncology follow-up were indicated.

Skin thickness as a potential marker of gestational age at birth despite different fetal growth profiles: A feasibility study.

BACKGROUND: New methodologies to estimate gestational age (GA) at birth are demanded to face the limited access to obstetric ultrasonography and imprecision of postnatal scores. The study analyzed the correlation between neonatal skin thickness and pregnancy duration. Secondarily, it investigated the influence of fetal growth profiles on tissue layer dimensions. METHODS AND FINDINGS: In a feasibility study, 222 infants selected at a term-to-preterm ratio of 1:1 were assessed. Reliable information on GA was based on the early ultrasonography-based reference. The thicknesses of the epidermal and dermal skin layers were examined using high-frequency ultrasonography. We scanned the skin over the forearm and foot plantar surface of the newborns. A multivariate regression model was adjusted to determine the correlation of GA with skin layer dimensions. The best model to correlate skin thickness with GA was fitted using the epidermal layer on the forearm site, adjusted to cofactors, as follows: Gestational age (weeks) = -28.0 + 12.8 Ln (Thickness) - 4.4 Incubator staying; R2 = 0.604 (P<0.001). In this model, the constant value for the standard of fetal growth was statistically null. The dermal layer thickness on the forearm and plantar surfaces had a negative moderate linear correlation with GA (R = -0.370, P<0.001 and R = -0.421, P<0.001, respectively). The univariate statistical analyses revealed the influence of underweight and overweight profiles on neonatal skin thickness at birth. Of the 222 infants, 53 (23.9%) had inappropriate fetal growths expected for their GA. Epidermal thickness was not fetal growth standard dependent as follows: 172.2 (19.8) µm for adequate for GA, 171.4 (20.6) µm for SGA, and 177.7 (15.2) µm for LGA (P = 0.525, mean [SD] on the forearm). CONCLUSIONS: The analysis highlights a new opportunity to relate GA at birth to neonatal skin layer thickness. As this parameter was not influenced by the standard of fetal growth, skin maturity can contribute to clinical applications.

Deformidad de Madelung: presentación de un caso / Madelung deformity: case report

La deformidad de Madelung es una alteración poco común de la articulación de las muñecas, con una prevalencia desconocida por los pocos casos reportados hasta la actualidad. Se vincula a mutaciones del gen SHOX. Se caracteriza por presentar alteraciones en el radio, el carpo y el cúbito, con predominio bilateral. Afecta principalmente a pacientes de sexo femenino; los signos y síntomas se revelan al inicio de la adolescencia. Presentamos el caso clínico de una paciente de sexo femenino de 17 años que registra las manifestaciones clínicas y radiográficas características. (AU)

Madelung deformity is a rare alteration of the wrist joint of unknown prevalence due to the few cases reported. It has been linked to SHOX gene mutations. Madelung deformity is characterized by alterations of the radius, carpus and ulna, predominantly bilateral and mainly seen in female patients at the beginning of the adolescence. We report the clinical case of a 17-yearold female patient presenting the characteristic clinical and radiographic deformities. (AU)

Bier's spots with onset in childhood

Abstract Bier spots are small, irregular, hypopigmented macules that are usually found on the arms and legs. The macules disappear when the limb is raised. Bier spots have been reported in association with a number of conditions but there is no consistent association to specific desease. Although they usually affect young adults, we report a case of Bier spots that began in childhood. As an asymptomatic and possibly transitional condition, the disease does not require treatment.

Bier's spots with onset in childhood.

Bier spots are small, irregular, hypopigmented macules that are usually found on the arms and legs. The macules disappear when the limb is raised. Bier spots have been reported in association with a number of conditions but there is no consistent association to specific desease. Although they usually affect young adults, we report a case of Bier spots that began in childhood. As an asymptomatic and possibly transitional condition, the disease does not require treatment.

Síndrome compartimental en el antebrazo: consideraciones anatomo-quirúrgicas / Compartment syndrome in forearm: anatomical and surgical considerations

Introducción: El síndrome compartimental es una situación en lacual el incremento de la presión dentro de un espacio cerrado,porencima de la presión de perfusión, afecta la circulación de lostejidos que están dentro de dicho espacio, comprometiendo lavitalidad de los mismos y ocasionando lesión tisular. En miembrosuperior se describen numerosos compartimientos en los queIntroducción: El síndrome compartimental es una situación en lacual el incremento de la presión dentro de un espacio cerrado,porencima de la presión de perfusión, afecta la circulación de lostejidos que están dentro de dicho espacio, comprometiendo lavitalidad de los mismos y ocasionando lesión tisular. En miembrosuperior se describen numerosos compartimientos en los quepodría ocurrir dicho fenómeno ,y es particularmente el antebrazouna de las regiones anatómicas donde suele suceder con mayorfrecuencia. Objetivo: Evaluar el conocimiento anatómico de los compartimientos en el antebrazo con posibilidad de sufrir unsíndrome compartimental para la realización de abordajesquirúrgicos de urgencia. Material y Método: Se realizaron encuestas anónimasevaluando el conocimiento anatómico sobre el tema a 11médicos cirujanos en formación y a 25 ayudantes de anatomía...

Introduction: Compartment syndrome is a situation in which increassed pressure within a closed space above perfusión pressure affects the tissues’ circulation into that space,compromising the vitality of them and causing tissue injury.In upper limb there are many compartments where this fenomenous may occur, and the forearm is one of the anatomicregions where normally occure more frequently. Objectives: To evaluate the anatomic knowledge of the forearm compartements with possibility of having a compartmentsyndrome for the realization of urgent surgical approaches. Material and Methods: Anonymous surveys were conducted toevaluate the anatomical knowledge of the subject to 11 trainingsurgeons and 25 anatomy assistants...

Formación de un solo hueso en antebrazo, en pseudoartrosis infectada de cúbito proximal / Formation of a single bone in the forearm in infected pseudoarthrosis of the proximal ulna

Propósito: Presentar el resultado exitoso de la técnica de formación de un solo hueso en antebrazo en un paciente con fractura inicial de cúbito con múltiples osteosíntesis e injertos fallidos. Caso: Paciente masculino dedicado a labores del campo que, a los 39 años de edad, sufre fractura de cúbito izquierdo, después de una evolución de 13 años y 5 intervenciones quirúrgicas con diversos tipos de osteosíntesis e injertos fallidos, que finalizaron en seudoartrosis infectada de cúbito izquierdo, decidiendo efectuarle la formación de un solo hueso en antebrazo evolucionando satisfactoriamente en función. Actualmente: supinación de 20º de antebrazo, flexoextensión de codo y muñeca completas, fuerza muscular adecuada, actualmente integrado en su trabajo de campo sin limitaciones funcionales. Conclusión: La técnica de formación de un solo hueso en antebrazo es, en casos adecuadamente seleccionados, una excelente alternativa de cirugía de reconstrucción o de salvamento en extremidad torácica.

Purpose: To present the successful results of the single-bone reconstruction technique in the forearm in a patient who sustained an ulnar fracture and underwent multiple osteosyntheses and failed grafts. Case: Male patient, agricultural worker, who at age 39 sustained a left ulnar fracture. After 13 years and 5 surgeries involving different types of osteosyntheses and failed grafts, which resulted in infection of the left ulnar pseudoarthrosis, we decided to do a single-bone reconstruction of the forearm. He did well and achieved good function. His current status is: 20º of forearm supination, full elbow and wrist flexion and extension, appropriate muscle strength, and he returned to his job without functional limitations. Conclusion: The single-bone forearm reconstruction technique is, in properly selected cases, an excellent surgical alternative when reconstruction or salvage of the thoracic limb is required.

Development and Validation of a Clinical Scale for the Evaluation of Forearm Skin Photoaging.

BACKGROUND: Despite the focus on facial photoaging ratings, there are few classifications developed for forearm skin aging assessment. OBJECTIVE: To develop and validate a clinical scale for the evaluation of forearm skin aging. METHODS: Three clinical dermatology faculty members selected, discussed, and appraised the main signs of forearm photoaging. The validation of the resulting scale was performed by 5 assessors who were previously trained to classify 102 photographs of forearms with different degrees of aging. Retests were performed in 15 days. RESULTS: There was significant correlation between the selected variables and the subjective global aging scale. The developed scale showed high internal consistency (Cronbach's α=0.87) and high correlation with the global photoaging scale (rho=0.92). Inter- and intraobserver final scores showed high agreement. CONCLUSION: A validated clinical photoaging scale for forearms with internal consistency, reliability, and validity was developed.

[Formation of a single bone in the forearm in infected pseudoarthrosis of the proximal ulna]. / Formación de un solo hueso en antebrazo, en pseudoartrosis infectada de cúbito proximal.

PURPOSE: To present the successful results of the single-bone reconstruction technique in the forearm in a patient who sustained an ulnar fracture and underwent multiple osteosyntheses and failed grafts. CASE: Male patient, agricultural worker, who at age 39 sustained a left ulnar fracture. After 13 years and 5 surgeries involving different types of osteosyntheses and failed grafts, which resulted in infection of the left ulnar pseudoarthrosis, we decided to do a single-bone reconstruction of the forearm. He did well and achieved good function. His current status is: 20° of forearm supination, full elbow and wrist flexion and extension, appropriate muscle strength, and he returned to his job without functional limitations. CONCLUSION: The single-bone forearm reconstruction technique is, in properly selected cases, an excellent surgical alternative when reconstruction or salvage of the thoracic limb is required.

Case for diagnosis.

We report the case of an 11-year-old male patient with a histopathological and immunohistochemical diagnosis of dermatofibroma with an atypical clinical presentation on the right forearm. Although dermatofibroma is considered a benign skin tumor, some of its differential diagnoses, such as dermatofibrosarcoma protuberans and malignant fibrous histiocytoma, are truly aggressive. Lesions with atypical clinical aspects and topology associated with specific histopathological variants are some of the criteria for complete tumor excision.

Case for diagnosis

We report the case of an 11-year-old male patient with a histopathological and immunohistochemical diagnosis of dermatofibroma with an atypical clinical presentation on the right forearm. Although dermatofibroma is considered a benign skin tumor, some of its differential diagnoses, such as dermatofibrosarcoma protuberans and malignant fibrous histiocytoma, are truly aggressive. Lesions with atypical clinical aspects and topology associated with specific histopathological variants are some of the criteria for complete tumor excision.

Five percent 5-fluorouracil in a cream or for superficial peels in the treatment of advanced photoaging of the forearms: a randomized comparative study.

BACKGROUND: The antimetabolite 5-fluorouracil (5-FU) is used for topical treatment of actinic keratosis. Overall improvement in the skin is also observed. Additionally, 5-FU was reported to be used for superficial peels. OBJECTIVES: To evaluate the efficacy and safety of 5% 5-FU cream compared with peels for photodamaged forearms. METHODS: This interventional, randomized, comparative, evaluator-blind study included 32 patients with severe photoaging of forearms. The regimens comprised either application of 5% 5-FU cream everyday for 4 weeks on 1 forearm and 4 weekly peels on the other. Efficacy assessment included: clinical photodamage scores, opinion of patients and investigators, and blind photographic evaluation by independent observers. Skin biopsies were performed for histologic and immunohistochemical analysis. Safety evaluation comprised observation of adverse events. RESULTS: Clinical and histologic findings confirmed the benefits of topical 5% 5-FU, in cream or peels, which improved skin appearance and decreased the dermal elastotic material. Immunohistochemistry showed reduced levels of epidermal p53 and increase in the level of procollagen I. Results were maintained after 6 months. Predictable adverse events occurred, with no differences between treatments. Patients reported better tolerability to peels. CONCLUSION: Five percent 5-FU cream or peels was safe and effective for the treatment of photodamaged forearms. Decreased epidermal p53 levels and new dermal collagen were confirmed.

Rhinocladiella aquaspersa, proven agent of verrucous skin infection and a novel type of chromoblastomycosis.

We report a case of chromoblastomycosis which resembled sporotrichosis due to the presence of warty nodules and lymphatic distribution on the forearm in a 56-year-old male. Mycological and histopathological investigation of exudates and biopsy tissue samples revealed a granulomatous lesion with muriform cells, the hallmark of chromoblastomycosis. The infection showed only localized expansion with verrucous plaques suggesting a new clinical type of the disease. The causative agent was identified as Rhinocladiella aquaspersa. This case prompted a study of the clinical spectrum of R. aquaspersa, through which we identified a second case caused by this fungus in a 62-year-old Brazilian female. The case was unusual in that R. aquaspersa exhibited hyphae rather than muriform cells in tissue. Given the difficulties treating chromoblastomycosis and other infections caused by melanized fungi, we evaluated the in vitro activities of extended-spectrum triazoles, amphotericin B, and echinocandins against these clinical isolates of R. aquaspersa. Itraconazole (MIC; 0.063 mg/l) and posaconazole (MIC; 0.125 mg/l) had the highest in vitro activities, while voriconazole and isavuconazole had somewhat lower activities (MICs; 2 mg/l) against the isolates. Amphotericin B and anidulafungin each had an MIC of 1 mg/l, whereas the MIC of caspofungin was 8 mg/l.

Validação diagnóstica da densitometria óssea de antebraço para o rastreamento da desmineralização óssea axial / Validation study of forearm bone densitometry for axial bone demineralization screening

Osteoporose é caracterizada pela diminuição da massa óssea e deterioração da micro-arquitetura, que eleva o risco global de fratura, diminui a expectativa e a qualidade de vida. É a doença ósseo-metabólica mais prevalente e de grande impacto sócio-econômico, considerada mundialmente um dos agravos mais importantes para a saúde pública. Apesar da OMS ter definido o DXA de coluna e fêmur, como padrão-ouro para diagnóstico, prognóstico e monitoramento da densidade mineral óssea, segundo o T-Score: -1,0DP - DMO normal; = -1,0DP a - 2,5DP - osteopenia; = -2,5DP - osteoporose, com risco de fratura duplicado, a cada aumento de -1,0DP, é inviável economicamente e se questiona a extrapolação do TS como medida de referência. Como os DXA de antebraço são mais baratos, simples e portáteis, além de emitirem menos radiação, são indicados para rastreamento de desmineralização óssea axial ou orientação terapêutica, caso o TS seja = -1,0DP. Este estudo objetivou avaliar o desempenho da densitometria do antebraço, utilizando o TS = -1,0DP, frente a baixa massa óssea axial; e, validar as DMO do rádio distal e do ultradistal, para o rastreamento da desmineralização óssea axial. Foram estudadas 189 mulheres (50-65 anos), saudáveis e na pós-menopausa, através de densitometrias periféricas e axiais. Para avaliar a habilidade do TS = - 1,0DP do novo teste, em diagnosticar pacientes com baixa massa óssea no padrãoouro, utilizaram-se indicadores de validação diagnóstica. A curva ROC identificou limiares das DMO de antebraço mais sensíveis e acurados. O teste de McNemar comparou os indicadores utilizando o TS e a DMO. Estipulou-se a significância estatística em 0,05. Os sítios do antebraço, utilizando o TS, apresentaram-se mais específicos (81 por cento-83 por cento) que sensíveis (64 por cento-63 por cento), com acurácia de quase 68 por cento, para rastreamento de desmineralização óssea na coluna. As DMO = 0,488g/cm2 do rádio distal e = 0,388g/cm2 do ultradistal, frente ao TS da coluna, elevaram a sensibilidade e a acurácia para 90 por cento e 80 por cento, diminuíram a especificidade para 60 por cento e as prevalências quase se equipararam à do padrão-ouro (79 por cento-81 por cento). A utilização do TS para diagnosticar baixa massa óssea axial, comprometeu a habilidade da densitometria do antebraço; enquanto a capacidade da mesma em selecionar corretamente mulheres saudáveis e na pós-menopausa com maior propensão a desmineralização óssea na coluna, e que se beneficiariam mais em confirmar esse diagnóstico ou iniciar uma terapêutica, ajustou-se após emprego das DMO.