Alberto Alzate

The minigrafting test for vitiligo: Detection of stable lesions for melanocyte transplantation

BACKGROUND Selected patients with stable and refractory vitiligo may consider melanocyte transplantation as a therapeutic alternative. A method to anticipate the response to surgical repair is not available. OBJECTIVE We evaluated the pigment spread of minigrafts when implanted within achromic lesions of stable vitiligo as a test to identify good candidates for surgical repigmentation. METHODS Four to six minigrafts of 1.0 to 1.2 mm were implanted within lesions of patients with unilateral (localized) and bilateral (generalized) vitiligo. Pigment spread was assessed 3 months later. RESULTS Forty-seven subjects were examined. In unilateral vitiligo 19 of 20 patients (95%) had a positive test result in comparison with only 13 of 27 patients (48%) with bilateral vitiligo (p = 0.002). CONCLUSION The minigrafting test is a reliable tool to identify patients with stable vitiligo who may respond to melanocyte transplantation. Unilateral (localized) vitiligo is the best indication for surgical repigmentation.

An epidemiologic case-control study in a population with vitiligo

BACKGROUND Previous epidemiologic studies of vitiligo have not included a sex- and age-matched population. OBJECTIVE Our purpose was to attempt to determine possible risk factors and clinical differences associated with unilateral and bilateral vitiligo. METHODS Two hundred thirty-four patients and 234 normal control subjects were examined and questioned. RESULTS Patients with unilateral vitiligo were younger and had an earlier age at onset. Koebners phenomenon and halo nevus were infrequent in the total vitiligo group, but no difference between vitiligo types was observed. Subjects with bilateral vitiligo more frequently had light skin (types I, II, and III) and more commonly had an associated autoimmune disease. CONCLUSION Unilateral and bilateral vitiligo differ substantially in several clinical aspects, which suggests a different pathogenic mechanism for each condition.

On the pathogenesis of idiopathic guttate hypomelanosis

Idiopathic guttate hypomelanosis is a common leukodermic dermatosis of obscure origin, consisting of small 2- to 5-mm achromic or hypopigmented macules, mainly affecting the exposed upper and lower extremities. In a group of 400 consecutive dermatologic patients, idiopathic guttate hypomelanosis was much more prevalent in women than in men. However, in both sexes this prevalence became more common with advancing age. In another group of fifteen patients with idiopathic guttate hypomelanosis and fifteen normal controls matched by age, sex, and skin type, the following was found: A cause-effect relationship between chronic actinic exposure and the development of idiopathic guttate hypomelanosis could not be established by statistical studies. A family aggregation survey disclosed a higher prevalence of idiopathic guttate hypomelanosis in the family of patients with idiopathic guttate hypomelanosis than in the control group. Epithelial atrophy, patchy absence of melanocytes and melanin, flattening of the rete pegs, and basket weave hyperkeratosis were the most prominent histologic findings of idiopathic guttate hypomelanosis. Minigrafts of normal skin implanted in idiopathic guttate hypomelanosis lesions did not modify the achromic defects, whereas intralesional triamcinolone with or without grafts improved the appearance of these lesions.

Malaria in gold-mining areas in Colombia

Gold-mining may play an important role in the maintenance of malaria worldwide. Gold-mining, mostly illegal, has significantly expanded in Colombia during the last decade in areas with limited health care and disease prevention. We report a descriptive study that was carried out to determine the malaria prevalence in gold-mining areas of Colombia, using data from the public health surveillance system (National Health Institute) during the period 2010-2013. Gold-mining was more prevalent in the departments of Antioquia, Córdoba, Bolívar, Chocó, Nariño, Cauca, and Valle, which contributed 89.3% (270,753 cases) of the national malaria incidence from 2010-2013 and 31.6% of malaria cases were from mining areas. Mining regions, such as El Bagre, Zaragoza, and Segovia, in Antioquia, Puerto Libertador and Montelíbano, in Córdoba, and Buenaventura, in Valle del Cauca, were the most endemic areas. The annual parasite index (API) correlated with gold production (R2 0.82, p < 0.0001); for every 100 kg of gold produced, the API increased by 0.54 cases per 1,000 inhabitants. Lack of malaria control activities, together with high migration and proliferation of mosquito breeding sites, contribute to malaria in gold-mining regions. Specific control activities must be introduced to control this significant source of malaria in Colombia.

HLA‐DQ3 is associated with idiopathic guttate hypomelanosis, whereas HLA‐DR8 is not, in a group of renal transplant patients

Background  The etiology of idiopathic guttate hypomelanosis (IGH) remains uncertain; however, solar exposure and heredity have been proposed as causative factors.

Infecciones micobacterianas en pacientes infectados por el virus de la inmunodeficiencia humana en Cali, Colombia

Se determino la prevalencia de las infecciones por micobacterias en una muestra de 155 individuos infectados por el virus de la inmunodeficiencia humana (VIH) tratados en el Instituto de los Seguros Sociales (ISS) de Cali, Colombia. Se les realizo la prueba de la tuberculina (PPD 2UT RT23) y se investigo activamente la presencia de micobacterias mediante microscopia directa y cultivo de sangre, orina, heces y aspirado gastrico; cuando asi lo indico el cuadro clinico, tambien se examinaron y cultivaron muestras de liquido cefalorraquideo, medula osea y esputo. La ausencia de reactividad a la tuberculina fue significativamente mas frecuente en los pacientes que en los controles (91,3%, frente a 57,4%. ji² = 33; P = 0). La prevalencia de la tuberculosis fue de 6,5%, en comparacion con 0,04% en los afiliados al ISS VIH-negativos (intervalo de confianza binomial exacto de 95%: 0,0313 a 0,1154%). Las micobacterias no tuberculosas (MNT), presentes en 43 pacientes, fueron significativamente mas frecuentes que Mycobacterium tuberculosis (27,7% frente a 6,5%. ji² = 24,78; P = 0,000 001), pero solo fueron causa de enfermedad en algunos casos. Las especies mas frecuentes fueron las del complejo M. avium-intracellulare. M. avium-intracellulare y M. fortuitum tuvieron una prevalencia total de 7,1% y fueron las MNT de mayor prevalencia como causantes de enfermedad en estos pacientes (4,5%); ademas fueron responsables de tres casos de infeccion diseminada. La enfermedad clinica por M. tuberculosis o MNT y la anergia completa a la tuberculina se asociaron al estadio IV de la infeccion por VIH y a los recuentos de linfocitos CD4 <= 400/µL. No obstante, la falta de respuesta inmunocelular, manifestada por una escasa reactividad a la tuberculina, se detecto desde el estadio de portador asintomatico del VIH. El progresivo deterioro del sistema inmunitario de los pacientes VIH-positivos es el factor determinante de la alta morbilidad y mortalidad de las infecciones por micobacterias, que requieren la pronta instauracion de quimioprofilaxis o tratamiento.The prevalence of mycobacterial infection was determined in 155 randomly selected HIV seropositive patients treated at the Social Security Institute in Cali Colombia. Each was given a tuberculin skin test (2 TU PPD RT23) and samples of blood urine feces and gastric aspirate were studied through direct microscopy and cultivation. The cerebrospinal fluid bone marrow and sputum were also examined and cultivated when clinically indicated. 67 of the 155 were asymptomatic carriers 27 had generalized persistent lymphadenopathy and 61 had AIDS. 61 patients from the trauma unit with no risk factors for HIV were controls. 137/150 patients (91.3%) and 35/61 controls (57.4%) showed absence of reactivity to tuberculin. The prevalence of mycobacterium was 34.8% in HIV patients. 10 (6.5%) had clinical tuberculosis 43 (27.7%) had nontuberculous mycobacteria (NTM) and in 1 case the type could not be determined. One case involved both. 8 of the 10 HIV seropositive patients with tuberculosis had full-blown AIDS. The infection was detected only through culture in 41 of the 43 NTM cases. The NTM was considered a possible cause of disease in 9 cases with M. fortuitum and M. avium-intracellulare the species most frequently implicated. 0.04% of controls were found to have tuberculosis. Lack of immunocellular response indicated by limited tuberculin reactivity was observed even in asymptomatic HIV carriers. Clinical disease caused by NTM or M. tuberculosis and complete tuberculin anergy were associated with full-blown AIDS and CD4 lymphocyte counts under 400.The prevalence of mycobacterial infections was determined in a sample of 155 individuals infected with human immunodeficiency virus (HIV) who were treated in the Social Security Institute (SSI) of Cali, Colombia. A tuberculin test (2 TU PPD RT23) was used, and the presence of mycobacteria was checked through direct microscopy and culturing blood, urine, feces, and gastric aspirate. When clinically indicated, samples of cerebrospinal fluid, bone marrow, and sputum were also examined and cultivated. The absence of reactivity to tuberculin was significantly more frequent in the patients than in the controls (91.3%, compared to 57.4%; chi 2 = 33, P = 0). The prevalence of tuberculosis was 6.5%, in comparison with 0.04% among a group of HIV-negative ISS members (exact binomial 95% confidence interval: 0.0313% to 0.1154%). Nontuberculous mycobacteria (NTM), present in 43 patients, were significantly more frequent than Mycobacterium tuberculosis (27.7%, versus 6.5%; chi 2 = 24.78, P = 0.000,001), but they caused illness only in some cases. The most common species were those of the M. avium-intracellulare complex. M. avium-intracellulare and M. fortuitum had a total prevalence of 7.1% and were the most-prevalent NTM that caused disease in these patients (4.5%); they were also responsible for three cases of disseminated infection. Clinical disease caused by M. tuberculosis or NTM and complete tuberculin anergy were associated with stage-IV HIV infection and with CD4 lymphocyte counts < or = 400/microL. However, the lack of immunocellular response, shown by limited tuberculin reactivity, was found beginning with the asymptomatic HIV carrier stage. The progressive deterioration of the immune system of HIV-positive patients is the determining factor in the high morbidity and mortality with mycobacteria infections and requires prompt chemoprophylaxis or treatment.

Comportamiento experimental del Sporothrix schenckii y la Leishmania mexicana en el hamster

The macroscopic description of the pathogenic process of Sporothrix schenckii and Leishmania mexicana spp in hamsters inoculated subcutaneously in the nose provided bases for the differentiation of the behavior of these two microorganisms in a model frequently utilized for their study. Sequential observations over 150 days demonstrated that infections caused by these pathogens results initially in edema and erythema followed by loss of hair, necrosis and ulceration. The pus production was a characteristic presented only by S. schenckii. These clinical signs were observed earlier in sporotrichosis than in L. mexicana infection. Differences in the mean day of appearance were statistically significant. The lesions produced by S. schenckii and L. mexicana in this experimental model share clinical signs, but their incubated period and relative frequency allow us to differentiate them. The circumstances of inoculation such as strain, dose of inoculum, place and route of inoculation are related to the experimental behavior of them.

Substance P may play a part during depigmentation in vitiligo. A pilot study.

To the Editor Subcorneal pustular dermatosis (SCPD) was first described as a distinct entity by Sneddon and Wilkinson in 1956 1 . It is characterized by a chronic relapsing pustular eruption predominantly involving the flexures and trunk 2 in middleaged women. We report a case of SCPD in a young female which was present in an atypical distribution as it was localized solely to the extensors of distal extremities. A 27-year-old woman presented with a 3-month history of multiple small pustular lesions on her extremities. She developed minimally itchy tiny pustular lesions over her hands and feet which gradually increased in number and size. There was no associated fever or any other systemic complaint. Ten months before she had experienced a similar eruption which had subsided following treatment, the nature of which was not known. There was nothing to suggest rheumatic or bowel related problems. Examination revealed flaccid pea-sized pustules on normal skin, distributed predominantly over the extensor aspect of the extremities, dorsa of hands and feet. In the majority of lesions pus had accumulated in the lower half of the pustule, leaving clear fluid in the upper half, forming characteristic hypopyon (fig. 1). In places the pustules had coalesced to form annular or polycyclic lesions with scaly edges. Smear and culture samples taken from a lesion showed numerous polymorphonuclear cells but no micro-organism. Investigations, including haemogram, biochemistry, serum electrophoresis, rheumatoid factor and ANA, were within normal limits. A biopsy taken from a lesion on the shin showed a subcorneal pustule with polymorphonuclear leukocytes with dermal perivascular inflammatory infiltrate composed of neutrophils and lymphomononuclear cells. Immunofluoresence studies were negative. The patient was given 100 mg dapsone twice-daily, following which there was dramatic improvement with complete resolution of lesions within 10 days. Sneddon–Wilkinson disease (a chronic, benign, relapsing, pustular eruption) can affect all age groups, even children. 3 The etiopathogenesis of SCPD is not clear but it has been reported in association with gammopathies, 4 pyoderma gangrenosum, 5

Diagnóstico precoce da hanseníase: o caso dos serviços de saúde no Recife(Pernambuco), Brasil

O presente trabalho e um estudo descritivo, realizado na cidade do Recife de marco a setembro de 1994. O estudo buscou caracterizar as condicoes existentes nos servicos de saude para o diagnostico precoce de hanseniase, com enfase na acessibilidade dos usuarios aos servicos e na qualidade do atendimento. A amostra constou de 32 servicos de saude utilizados durante o processo diagnostico de 183 pacientes de hanseniase. A infra-estrutura organizacional foi caracterizada atraves de entrevistas com os gerentes dos servicos. O funcionamento foi investigado atraves de observacoes da rotina dos servicos, em particular as atividades de arquivo e triagem. Um total de 1998 pacientes foram entrevistados para determinar a facilidade de acesso. Para 1 000 pacientes foi estabelecido o tempo de consulta com os 123 medicos que estavam nas unidades no momento da amostragem. Para explorar a atitude e o conhecimento dos medicos sobre a hanseniase, selecionou-se, aleatoriamente, a partir de uma listagem nominal, 133 medicos destes servicos. Identificaram-se como dificuldades para o diagnostico precoce de hanseniase: a sistematica demanda reprimida (pessoas que procuravam os servicos mas nao eram atendidas); o longo tempo entre momento de marcacao e momento de realizacao de consultas (para pessoas que nao eram atendidas no mesmo dia); os longos tempos de espera pela consulta dentro dos servicos; a curta duracao da consulta; a baixa disponibilidade de recursos humanos treinados; a baixa proporcao de medicos que examinam toda a superficie corporal; as deficiencias no reconhecimento clinico da doenca e no conhecimento que leva ao diagnostico diferencial. Estes obstaculos podem facilitar a deterioracao fisica dos portadores de hanseniase e a persistencia da transmissibilidade; portanto, necessitam ser superados para que seja possivel eliminar a hanseniase.

Epidemiology of a natural focus of Leishmania braziliensis in the Pacific lowlands of Colombia. III. Natural infections in wild mammals

A natural infection of Leishmania braziliensis panamensis in the edentate, Choloepus hoffmanni is recorded from the Pacific Coast of Columbia.