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Clinical exuberance of Hansen disease: Case report
INFECTION—BACTERIAL AND PARASITIC P6833 Acute ulcerative lesions in HIV seropositive patient Fred Bernardes Filho, MD, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Andreia Oliveira Alves, Universidade Metropolitana de Santos (UNIMES), Santos, Brazil; Fernanda de Figueiredo Bongiovani, Universidade de Ribeir~ao Preto (UNAERP), Ribeir~ao Preto, Brazil; Jose Augusto da Costa Nery, PhD, MD, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Maria Vict oria Quaresma, MD, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Renata Pinto Fernandes Timb o, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Yamileth Cruz Ararat, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil Background: In HIV-infected patients, the syphilis coinfection is common and both diseases can mutually affect each other, resulting in alteration of serological responses or even a more severe clinical manifestation. Those patients have an increased chance of manifesting a more malign disease course, more constitutional symptoms and a larger number of infected organs. Observing that, the immunologic system dysfunction in AIDS is a possible explanation for the increased case numbers in this population. The infection has now found a new way; instead of spontaneous cure, the syphilis immunodepressed patients evolve more clinical diseases. Case report: A 33-year-old man, single, born in Rio de Janeiro, came to the service for diffused body lesions, especially in the upper body, associated to fever and bad general state. He has had multiple sexual partners and a history of 6-year-old HIV infection in use of antiretroviral therapy seven months ago, indicated by immunodeficiency. Physical examination demonstrated erythematous papular plaques with central ulcerated surface, covered with thick hemorrhagic crusts in the upper body, upper limbs, region neck, chin and micropoliadenomagalia widespread. Hypotheses have been suggested such as cutaneous herpes, cytomegalovirus cutaneous atypical mycobacteriosis, pyoderma gangrenosum, and syphilis. Exams: VDRL titer to 1/128 and FTA-ABS IgM reactive. A diagnosis was established with early malignant syphilis. Therapy was started with 3 doses of benzathine penicillin 2,400,000 IU with an interval of 7 days. VDRL was performed with a negative result. When the patient returned 30 days after the completion of the treatment, he presented cleared cutaneous lesions, being accompanied by dermatology outpatient health. According to our industry’s protocol, the patient will have clinical reevaluation every 3 months and VDRL for a period of 2 years. Discussion: This case reforces that, for HIV seropositive patients presenting acute ulcerated lesions, syphilis suspicion and investigation must be mandatory. As coinfection in this scenario can lead to premature stages of invasive deceases, we must be aware of it. Our patient presented early malignant syphilis, secondary syphilis, although we opted for a 7,200,000 IU penicillin benzatine dose treatment for the patient’s safety. There is a necessity for more studies, demonstrating the efficacy of this drug according to the phases of syphilis coinfection with HIV. Commercial support: None identified.
P6799 Clinical management with endovenous corticotherapy in patients with leprosy reactions Fred Bernardes Filho, MD, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Andreia Oliveira Alves, Universidade Metropolitana de Santos (UNIMES), Santos, Brazil; Gisele Reis Cunha Silva, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Jose Augusto da Costa Nery, PhD, MD, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Maria Vict oria Quaresma, MD, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Ystannyslau Bernardes da Silva, MD, Hospital Benefic^encia Portuguesa de Ribeir~ao Preto, Ribeir~ao Preto, Brazil Background: The reactional states are considered either acute or subacute episodes characterized by cutaneous or systemic onsets because of changes in immunologic state. Early detection and the commence of antiinflammatory medication constitutes the key to therapeutics whose target is to avoid neural damage. The treatment of reverse reaction or leprosy reaction type 1 aims to suppress the cellular immunologic response and demands immediate and adequate intervention because of the risks of systemic damages. Clinically, they modify the reverse reactions in several ways: by reducing both the cutaneous and intraneural edema leading to a fast recovery in the symptomatology. Case report: Male patient, 65 years old, married, born in Rio de Janeiro was moved from the basic health unit to hospitalization for presenting a clinical condition of leprosy reactions type 1 without clinical response to oral therapy. The patient started tuberculoid leprosy treatment 5 months ago with paucibacillary polychemotherapy with prescription of 6 dosages. It is in his medical record that in the first 2 months the patient took the medication irregularly and, for this reason, he is forced to keep the treatment. For the past 10 days, based on the fact his condition was more acute, his preexisting lesions have worsened and he has experienced the onset of new lesions. Even after starting oral prednisone, the patient has not presented better conditions despite the fact his prescription is 80 mg/day. Through ectoscopy, it was observed the presence of several underlying erythematous patches throughout the tegument, edema and scaling of some lesions. As the reverse reaction was very adverse, the oral corticoid therapy was replaced by endovenous procedures being prescribed 1g/day of methylprednisolone for 3 consecutive days. The patient quickly improved his condition with intravenous corticoid therapy. Discussion: The objective of the treatment of the reverse reaction is to reduce inflammatory reaction, especially neural. We emphasize that at first multidrug therapy must be continued during reactional episode. Endovenous methylprednisolone or pulse therapy in indicated with the following dosages; 1g of endovenous methylprednisolone with a single dosage for three consecutive days and then 1g a week for four consecutive weeks. Between pulses, 0.5 mg/kg/day of prednisone with progressive reduction of the dosage keeping the same extreme precautions for the chronic use of corticoids. Commercial support: None identified.
P7044 Clinical exuberance of Hansen disease: Case report Delky Johanna Villarreal Villarreal, MD, Instituto de Dermatologia Professor Rubem David Azulay, Rio De Janeiro, Brazil; Aline Tanus Luz, MD, Instituto de Dermatologia Professor Rubem David Azulay, Rio De Janeiro, Brazil; Alissa Elen Formiga Moura, Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro, Brazil; Camila Caberlon Cruz Oliveira, MD, Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro, Brazil; Lizandra Fujita de Paula Pessoa, Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro, Brazil; Maria Vit oria Quaresma, MD, Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro, Brazil; Natasha Sim~ oes Montenegro, Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro, Brazil Background: Hansen disease is a contagious disease caused by Mycobacterium leprae which affects preferably skin and peripheral nerves. In Brazil in 2011, 34,000 new cases were registered and 45% of them were multibacillary form. Its classification is defined by clinical forms (the ‘‘multibacillary’’ Virchowiana Hansen and the ‘‘paucibacillary’’ tuberculoid Hansen) as well as other intermediate forms with hybrid characteristics. Individuals with some type of immunosuppression have the Virchowiana form of the disease, which is characterized by extensive skin and peripheral nerves involvement. This report shows a delay in diagnosis and treatment of disease. Case report: Male, black, age 75 years, from RJ (Brazil) relates paresthesia, anesthesia and edema of hands and feet, xerosis of skin which started 2 years ago. Dermatologic examination: Aspect malnourished, dry skin, On the face: Madarosis and atrichia bilateral, erythematous violaceous and infiltrated plaques on the forehead, jaw region, pavilions and bilateral ears lobules, erythematous violaceous lobulated nodule of 1.5 cm in diameter on the left side of the nose. On the upper limbs: Erythematous violaceous nodules, thickening and hardening of the ulnar nerves, swelling of the hands (3+/4+), flexion of the proximal phalanx of the 5th fingers, exulcerated lesions on the dorsum of the hands. On the lower limbs: Thickening and hardening of the popliteal nerves, swollen feet (3+/4+) with changes in temperature and pain sensitivity in boots and gloves, hammer toes, plantar keratosis with some areas exulcerations plantar pressure, bone resorption the second and third toes of the right foot. Smear-positive. Discussion: The diagnosis of Hansen disease is primaly clinical, epidemiologic, supplemented if possible with bacteriologic and histopathologic examination. The peripheral nerves and skin manifestations of the disease present a singular clinical picture that is easily recognized. However, ignorance about leprosy is common both in the general population and health personnel, reason why it continues to be a public health problem in several countries. This report illustrates as Hansen disease continues to be endemic in Brazil because of late diagnosis. Commercial support: None identified.
AB116
J AM ACAD DERMATOL
P7071 Cutaneous larva migrans: An imported case Carmen Martinez Peinado, Dermatology Department, Almeria, Spain; Francisca Simon, Dermatology Department, Almeria, Spain; Josefa Orero, Dermatology Department, Almeria, Spain; Mercedes Alcalde, Dermatology Department, Almeria, Spain; Paloma Nogueras, Dermatology Department, Granada, Spain; Pilar Gomez, Dermatology Department, Almeria, Spain Background: Cutaneous larva migrans (CLM), or creeping eruption of the skin, is caused by the migration of animal hookworm larvae in the human skin. Hookworms of dogs and cats, such as Ancylostoma caninum and A braziliense, are the usual causative agents. The typical clinical manifestation of this skin disease is an itchy, erythematous, linear or serpiginous, dermatitis tract. In most cases, the feet, buttocks and thighs represent the main anatomic site affected by CLM, but any part of the body in contact with infested soil or sand can be involved. Topical or oral thiabendazole, oral albendazole or a single-dose of ivermectin are effective treatment options. We describe a case in a Spanish patient, after a trip to Jamaica. Case report: A 33-year-old woman from Spain presented with a 2-week history of skin lesions on her legs and abdomen. The patient was VHC+. The lesions were intensely pruritic and red. She had returned from a trip to Jamaica 1 week before the onset of the lesions. On examination, she presentes multiple raised and erythematous serpiginous tracts. The findings were clinically consistent with cutaneous larva migrans. Complete blood count was normal. A skin biopsy showed nematode larvae close to hairs with paired spicules in the cuticle, which are typical of the ancylostoma. Treatment with albendazole 400 mg/12 hours for 4 days results in a complete recovery. Discussion: The diagnosis of cutaneous larva migrans is based on exposure history and morphology of skin lesions. The parasite is not always showed in skin biopsy. Humans are accidentally infected by the larvae from contaminated soil. The larva is unable to penetrate the dermis and remains in the epidermis and hair follicles, causing red swollen and serpiginous tracks. Scratching may cause extensive excoriations and subsequent bacterial superinfection of the lesions. The mainstay for prevention is the use of proper footwear when traveling to endemic areas. The disease causes intense pruritus and is associated with important morbidity, besides it is the most frequent tropical dermatosis. Commercial support: None identified.
APRIL 2013
P6799 Clinical management with endovenous corticotherapy in patients with leprosy reactions Fred Bernardes Filho, MD, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Andreia Oliveira Alves, Universidade Metropolitana de Santos (UNIMES), Santos, Brazil; Gisele Reis Cunha Silva, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Jose Augusto da Costa Nery, PhD, MD, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Maria Vict oria Quaresma, MD, Instituto de Dermatologia Prof. Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro, Brazil; Ystannyslau Bernardes da Silva, MD, Hospital Benefic^encia Portuguesa de Ribeir~ao Preto, Ribeir~ao Preto, Brazil Background: The reactional states are considered either acute or subacute episodes characterized by cutaneous or systemic onsets because of changes in immunologic state. Early detection and the commence of antiinflammatory medication constitutes the key to therapeutics whose target is to avoid neural damage. The treatment of reverse reaction or leprosy reaction type 1 aims to suppress the cellular immunologic response and demands immediate and adequate intervention because of the risks of systemic damages. Clinically, they modify the reverse reactions in several ways: by reducing both the cutaneous and intraneural edema leading to a fast recovery in the symptomatology. Case report: Male patient, 65 years old, married, born in Rio de Janeiro was moved from the basic health unit to hospitalization for presenting a clinical condition of leprosy reactions type 1 without clinical response to oral therapy. The patient started tuberculoid leprosy treatment 5 months ago with paucibacillary polychemotherapy with prescription of 6 dosages. It is in his medical record that in the first 2 months the patient took the medication irregularly and, for this reason, he is forced to keep the treatment. For the past 10 days, based on the fact his condition was more acute, his preexisting lesions have worsened and he has experienced the onset of new lesions. Even after starting oral prednisone, the patient has not presented better conditions despite the fact his prescription is 80 mg/day. Through ectoscopy, it was observed the presence of several underlying erythematous patches throughout the tegument, edema and scaling of some lesions. As the reverse reaction was very adverse, the oral corticoid therapy was replaced by endovenous procedures being prescribed 1g/day of methylprednisolone for 3 consecutive days. The patient quickly improved his condition with intravenous corticoid therapy. Discussion: The objective of the treatment of the reverse reaction is to reduce inflammatory reaction, especially neural. We emphasize that at first multidrug therapy must be continued during reactional episode. Endovenous methylprednisolone or pulse therapy in indicated with the following dosages; 1g of endovenous methylprednisolone with a single dosage for three consecutive days and then 1g a week for four consecutive weeks. Between pulses, 0.5 mg/kg/day of prednisone with progressive reduction of the dosage keeping the same extreme precautions for the chronic use of corticoids. Commercial support: None identified.
P7044 Clinical exuberance of Hansen disease: Case report Delky Johanna Villarreal Villarreal, MD, Instituto de Dermatologia Professor Rubem David Azulay, Rio De Janeiro, Brazil; Aline Tanus Luz, MD, Instituto de Dermatologia Professor Rubem David Azulay, Rio De Janeiro, Brazil; Alissa Elen Formiga Moura, Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro, Brazil; Camila Caberlon Cruz Oliveira, MD, Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro, Brazil; Lizandra Fujita de Paula Pessoa, Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro, Brazil; Maria Vit oria Quaresma, MD, Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro, Brazil; Natasha Sim~ oes Montenegro, Instituto de Dermatologia Professor Rubem David Azulay, Rio de Janeiro, Brazil Background: Hansen disease is a contagious disease caused by Mycobacterium leprae which affects preferably skin and peripheral nerves. In Brazil in 2011, 34,000 new cases were registered and 45% of them were multibacillary form. Its classification is defined by clinical forms (the ‘‘multibacillary’’ Virchowiana Hansen and the ‘‘paucibacillary’’ tuberculoid Hansen) as well as other intermediate forms with hybrid characteristics. Individuals with some type of immunosuppression have the Virchowiana form of the disease, which is characterized by extensive skin and peripheral nerves involvement. This report shows a delay in diagnosis and treatment of disease. Case report: Male, black, age 75 years, from RJ (Brazil) relates paresthesia, anesthesia and edema of hands and feet, xerosis of skin which started 2 years ago. Dermatologic examination: Aspect malnourished, dry skin, On the face: Madarosis and atrichia bilateral, erythematous violaceous and infiltrated plaques on the forehead, jaw region, pavilions and bilateral ears lobules, erythematous violaceous lobulated nodule of 1.5 cm in diameter on the left side of the nose. On the upper limbs: Erythematous violaceous nodules, thickening and hardening of the ulnar nerves, swelling of the hands (3+/4+), flexion of the proximal phalanx of the 5th fingers, exulcerated lesions on the dorsum of the hands. On the lower limbs: Thickening and hardening of the popliteal nerves, swollen feet (3+/4+) with changes in temperature and pain sensitivity in boots and gloves, hammer toes, plantar keratosis with some areas exulcerations plantar pressure, bone resorption the second and third toes of the right foot. Smear-positive. Discussion: The diagnosis of Hansen disease is primaly clinical, epidemiologic, supplemented if possible with bacteriologic and histopathologic examination. The peripheral nerves and skin manifestations of the disease present a singular clinical picture that is easily recognized. However, ignorance about leprosy is common both in the general population and health personnel, reason why it continues to be a public health problem in several countries. This report illustrates as Hansen disease continues to be endemic in Brazil because of late diagnosis. Commercial support: None identified.
AB116
J AM ACAD DERMATOL
P7071 Cutaneous larva migrans: An imported case Carmen Martinez Peinado, Dermatology Department, Almeria, Spain; Francisca Simon, Dermatology Department, Almeria, Spain; Josefa Orero, Dermatology Department, Almeria, Spain; Mercedes Alcalde, Dermatology Department, Almeria, Spain; Paloma Nogueras, Dermatology Department, Granada, Spain; Pilar Gomez, Dermatology Department, Almeria, Spain Background: Cutaneous larva migrans (CLM), or creeping eruption of the skin, is caused by the migration of animal hookworm larvae in the human skin. Hookworms of dogs and cats, such as Ancylostoma caninum and A braziliense, are the usual causative agents. The typical clinical manifestation of this skin disease is an itchy, erythematous, linear or serpiginous, dermatitis tract. In most cases, the feet, buttocks and thighs represent the main anatomic site affected by CLM, but any part of the body in contact with infested soil or sand can be involved. Topical or oral thiabendazole, oral albendazole or a single-dose of ivermectin are effective treatment options. We describe a case in a Spanish patient, after a trip to Jamaica. Case report: A 33-year-old woman from Spain presented with a 2-week history of skin lesions on her legs and abdomen. The patient was VHC+. The lesions were intensely pruritic and red. She had returned from a trip to Jamaica 1 week before the onset of the lesions. On examination, she presentes multiple raised and erythematous serpiginous tracts. The findings were clinically consistent with cutaneous larva migrans. Complete blood count was normal. A skin biopsy showed nematode larvae close to hairs with paired spicules in the cuticle, which are typical of the ancylostoma. Treatment with albendazole 400 mg/12 hours for 4 days results in a complete recovery. Discussion: The diagnosis of cutaneous larva migrans is based on exposure history and morphology of skin lesions. The parasite is not always showed in skin biopsy. Humans are accidentally infected by the larvae from contaminated soil. The larva is unable to penetrate the dermis and remains in the epidermis and hair follicles, causing red swollen and serpiginous tracks. Scratching may cause extensive excoriations and subsequent bacterial superinfection of the lesions. The mainstay for prevention is the use of proper footwear when traveling to endemic areas. The disease causes intense pruritus and is associated with important morbidity, besides it is the most frequent tropical dermatosis. Commercial support: None identified.
APRIL 2013