Carmen Lisboa

Prevalence, Distribution, and Antifungal Susceptibility Profiles of Candida parapsilosis, C. orthopsilosis, and C. metapsilosis in a Tertiary Care Hospital

ABSTRACT Candida parapsilosis, an emergent agent of nosocomial infections, was previously made up of a complex of three genetically distinct groups (groups I, II, and III). Recently, the C. parapsilosis groups have been renamed as distinct species: C. parapsilosis sensu stricto, C. orthopsilosis, and C. metapsilosis. In Portugal, no data pertaining to the distribution and antifungal susceptibility of these Candida species are yet available. In the present report, we describe the incidence and distribution of C. parapsilosis sensu stricto, C. orthopsilosis, and C. metapsilosis among 175 clinical and environmental isolates previously identified by conventional methods as C. parapsilosis. We also evaluated the in vitro susceptibilities of the isolates to fluconazole, voriconazole, posaconazole, amphotericin B, and two echinocandins, caspofungin and anidulafungin. Of the 175 isolates tested, 160 (91.4%) were identified as C. parapsilosis sensu stricto, 4 (2.3%) were identified as C. orthopsilosis, and 5 (2.9%) were identified as C. metapsilosis. Six isolates corresponded to species other than the C. parapsilosis group. Interestingly, all isolates from blood cultures corresponded to C. parapsilosis sensu stricto. Evaluation of the antifungal susceptibility profile showed that only nine (5.6%) C. parapsilosis sensu stricto strains were susceptible-dose dependent or resistant to fluconazole, and a single strain displayed a multiazole-resistant phenotype; two (1.3%) C. parapsilosis sensu stricto strains were amphotericin B resistant. All C. orthopsilosis and C. metapsilosis isolates were susceptible to azoles and amphotericin B. A high number of strains were nonsusceptible to the echinocandins (caspofungin and anidulafungin).

Dermatological and Ophthalmological Sequels in Toxic Epidermal Necrolysis

Background: Toxic epidermal necrolysis (TEN) is a rare, drug-induced disease characterized by epidermal detachment and mucosal involvement. After an acute period, potentially disabling cutaneous and ocular sequels may appear. Although long-term complications are not rare, only few outcome studies are published. Objective: To evaluate the incidence of dermatological and ophthalmological sequels following TEN, to describe its clinical aspects and correlation with acute involvement. Patients and Methods: Eight patients surviving to TEN were submitted to dermatological and ophthalmological observation ranging from 0.5 to 8 years after hospitalization. Cutaneous and ocular involvement, during the acute phase, was retrospectively analysed. Results: Dermatological sequels were observed in 6 patients (75%) corresponding to those with more extensive skin involvement in the acute phase. The most frequent complications were cutaneous dyschromia (62.5%) and nail dystrophies (37.5%). Six patients (75%) had ocular complications with tarsal conjunctiva keratinization in 5 (62.5%) and keratoconjunctivitis sicca in 4 of them (50%). Trichiasis, corneal neovascularization and symblepharon were observed in 1 case. There was no correlation between the severity of acute ocular involvement and long-term complications. Conclusion: Following TEN, most patients have dermatological and ophthalmological sequels that persist for several years.

A case of toxic epidermal necrolysis treated with intravenous immunoglobulin

q 2000 British Association of Dermatologists, British Journal of Dermatology, 142, 177±199 response to IFN began to be appreciable within the third and fourth week of treatment in all patients, similar to that seen with daily injections. Overall, there was a striking 50% or more regression of the IHs within 8 months of treatment, a result comparable to that of other authors who used the higher dose regime (Fig. 1a±d). It is also noteworthy that an earlier onset of treatment resulted in a more rapid and evident reduction of IHs (patients 3±5). In none of our patients did regrowth of IHs follow withdrawal of the drug; instead, lesion involution continued. Side-effects were a mild febrile reaction in the first weeks of therapy in three patients and a modest transient increase of transaminases in the second and third month in only one patient. In no case did treatment have to be discontinued and no long-term sequelae have been noted during follow up over at least 2 years. In particular, spastic diplegia was not observed, either in the present study or in the 11 patients reported in the previous study. IHs are benign vascular tumours occurring in 1±2% of infants. Their frequency is higher in girls, with a sex ratio ranging from 5 : 1 to 2 : 1. IHs undergo a proliferative phase, from birth to 6±20 months, and then an involutional phase beginning at 6 months to 1 year and continuing for the next 5±7 years. A small proportion of IHs are complicated by the obstruction of important structures such as the periorbital region, nose, lips, airways and perianal region. These problematic, alarming or complex IHs require treatment. The classical therapy for IHs consists of systemic corticosteroids, but subcutaneous IFN is a valid alternative therapy; IHs are among the first established indications for antiangiogenic therapy in humans. A recent study provided evidence of high levels of positive angiogenic factors but absence of the endogenous inhibitor, IFN, in the proliferative tissue of IHs. IFN is usually given at high doses, beginning with an initial dose of 1 million U/m per day. If tolerated, the dose is increased to 2±3 million U/m per day and then maintained at this level for many months. In a previous paper we provided evidence indicating that lower doses are equally effective. The following schedule was suggested: 1 million U/m per day three times a week for 2 weeks, then increased to 3 million U/m per day three times a week for the duration of the treatment. This schedule was as effective as a dose of 3 million U/m per day for a similar time. In particular, we obtained results comparable to those of Ezekowitz et al. and Ohlms et al. The present study provides evidence that further reduction of the IFN dose did not diminish the efficacy of the treatment, i.e. the speed of reduction in size of IHs proceeded at the same rate as with a dose of 3 million U/m per day. This is noteworthy because the cost of treatment is reduced by 60% and IFN side-effects are alleviated. In conclusion we believe that IFN, at the low doses we suggested, should be considered the first-line agent for treatment of IHs, as the recommended systemic corticosteroid schedule not only achieves lower response rates but induces T-cell suppression and growth retardation, side-effects that limit corticosteroid use in the infant population. Acknowledgments

Infectious balanoposthitis: management, clinical and laboratory features

Background  Balanitis is defined as inflammation of the glans penis, often involving the prepuce (balanoposthitis). It is a common condition due to a wide variety of causes with infection being the most frequent and several microorganisms reported. The clinical aspect is often non specific. The management of balanoposthitis remains a clinical challenge.

Cutaneous alternariosis by Alternaria chartarum in a renal transplanted patient.

Sir, Langerhans cell histiocytosis (LCH) includes a spectrum of disorders with overlapping clinical features, i.e. Letterer±Siwe disease, Hand±SchuÈ ller±Christian syndrome, eosinophilic granuloma and congenital self-healing reticulohistiocytosis. The typical cutaneous findings comprise seborrhoeic dermatitis-like lesions, reddish-brown purpuric papules and nodules, oozing erosions, and ulcerations. A child with LCH is described, who presented with an uncommon pattern of pustular lesions on the forehead, hands, feet and genital region, following an atypical clinical course. One week after birth, a 14-month-old girl developed multiple, sharply demarcated itchy pustules on the forehead, together with red papules, and pustules partly covered with haemorrhagic crusts, which were predominantly on the soles of the feet (Fig. 1a). Some pustules occurred on the hands and in the genital and gluteal region. No lymphadenopathy was detectable. During topical treatment with lotio zinci (lotion with zinc oxide, talcum, glycerol and distilled water) the cutaneous lesions regressed slowly, but new lesions developed during the following months. After 5 months, an ulcer developed in the maxillary region. There was no specific family history of skin diseases. A skin biopsy of a pustule from the gluteal region revealed a dense upper dermal infiltrate of large histiocytes with a reniform nucleus, and intraepidermal collections of histiocytic cells (Fig. 1b). Immunohistochemical stains were positive for CD1 and for S-100 antigen. Electron microscopy revealed intracytoplasmic Birbeck granules within the histiocytic cells, thus confirming the diagnosis of LCH. Bacteriological and mycological examinations from skin lesions were negative. Full blood count, liver and kidney function were normal. Scintiscanning and radiography showed distinct involvement of the maxilla. Abdominal sonography was normal. Based on the occurrence of new cutaneous lesions and the subsequent involvement of the osseous part of the maxilla, chemotherapy was initiated with oral prednisolone 40 mg m daily for 4 weeks; then reduction of dose, vinblastine 0 ́2 mg kg once weekly for 6 weeks, then once monthly; and 6-mercaptopurine 50 mg m daily. Cutaneous lesions on the scalp, hands and feet, and the osseous lesion of the maxilla healed during the chemotherapy, which was performed for 1 years. In 1955, Lichtenstein summarized the three entities Letterer±Siwe disease, Hand±SchuÈ ller±Christian disease and eosinophilic granuloma under the term histiocytosis X. The cause of histiocytosis X (LCH) is unknown, but it is believed to be a proliferative process of Langerhans cells. Lesional histiocytes in the child described here were positive for S-100 antigen and CD1, as well as for intracytoplasmic Birbeck granules. The skin lesions did not clear completely

Candida balanitis: risk factors

Background  The amount of available information on the prevalence and incidence of candida balanitis is still surprisingly scarce.

Anti-TNF-alpha induced psoriasiform eruptions with severe scalp involvement and alopecia: report of five cases and review of the literature.

We describe 5 cases of anti-tumor necrosis factor-alpha (anti-TNF-α) induced psoriasiform eruptions with severe scalp involvement inducing inflammatory alopecia and review the literature on this subject. All our 5 patients were provided topical therapy, with good results in only 1 case. The remaining 4 were provided systemic therapy (methotrexate ± cyclosporine): 3 concomitantly suspended the anti-TNF-α treatment (2 are currently clear/almost clear but 1 has so far only observed mild improvement) and 1 switched anti-TNF-α (recurrent flare-ups of the disease continue). So far, no patient has developed scarring alopecia. To our knowledge, a total of 15 cases of anti-TNF-α induced psoriatic alopecia have been described. Anti-TNF-α was discontinued in 9 of the 15 patients and systemic therapy was provided to 9 of the 15 patients. Nonetheless, 2 patients developed scarring alopecia. We conclude that in anti-TNF-α induced psoriasiform eruptions some patients may respond to topical treatment, however in cases of severe scalp involvement anti-TNF-α suspension and systemic treatment should be considered in order to avoid scarring alopecia.

Genital candidosis in heterosexual couples

Background  Evidence suggests that Candida can be sexually transmitted; however, the contribution of sexual transmission to the pathogenesis of genital candidosis needs further elucidation.

Postzoster cutaneous pseudolymphoma in a patient with B-cell chronic lymphocytic leukaemia.

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Tuberculosis in a child presenting as asymptomatic oropharyngeal and laryngeal lesions.

Abstract: We describe an 11‐year‐old boy who had several, asymptomatic, erythematous papules in the oropharynx and larynx with recent onset, two cervical lymphadenopathies, and a painless, erythematous plaque on the right wrist with a 2.5‐year history of slow growth. Histologic examination of the mucocutaneous lesions revealed a submucous infiltrate of lymphocytes and Langhans giant cells in the papules and granulomatous dermatitis in the plaque. The cervical lymph node was biopsied and on the surgical scar, an erythematous, nodular lesion developed. A biopsy specimen of this lesion showed tuberculoid granulomas with prominent caseation necrosis, and culture was positive for Mycobacterium tuberculosis. The Mantoux test was strongly positive with a vesicular response. A diagnosis of mucocutaneous lupus vulgaris and scrofuloderma secondary to cervical tuberculous lymphadenitis was made. Two months after initiation of antituberculosis therapy there was a complete resolution of mucous lesions and healing with atrophic scars on the neck and wrist. This is a rare presentation in the literature and reminds clinicians that tuberculosis should be kept in mind in the differential diagnosis of oral cavity lesions.