Cidia Vasconcellos

Urticaria unresponsive to antihistaminic treatment: An open study of therapeutic options based on histopathologic features

Background: The non‐ or low‐sedating H1 receptor antagonists represent the basic therapy for urticaria. Objective: To test an alternative approach to patients unresponsive to conventional treatment. Materials and methods: A total of 22 patients with chronic urticaria unresponsive to conventional antihistamine treatment were enrolled for this study. They had uncontrolled urticaria even using multiple combinations of antihistamines on maximum doses and corticosteroids in short cycles (prednisone 20–40 mg, per os once a day, 3–7 days per month). Cutaneous biopsies of the urticaria lesions were taken. These findings were classified as: (I) a mixture of perivascular dermal inflammatory infiltrate composed of lymphocytes, monocytes and neutrophils and/or eosinophils; (II) inflammatory infiltrate composed chiefly of neutrophils; and (III) inflammatory infiltrate composed mainly of eosinophils. According to histology, the patients were submitted to one of the following therapeutic schemes: class A – antihistamine treatment plus dapsone; class B – colchicine or dapsone; class C – montelukast. Results: Four patients in class A, 08 in class B and seven in class C displayed complete control of urticaria after 12 weeks of treatment; one patient in class B and two in class C did not respond to treatment. Two years after discontinuation, 16 patients are still free of urticaria. Conclusions: This study suggests an alternative approach for treating unresponsive chronic urticaria.

Two case reports of cutaneous adverse reactions following hepatitis B vaccine: lichen planus and granuloma annulare.

We report two cases of adverse cutaneous reactions following hepatitis B vaccination. The first case occurred 3 weeks after the first dose of hepatitis B vaccine in a 16‐year‐old white girl with the onset of lichen planus lesions on her thighs and abdomen. After the second dose a disseminated lichen planus developed within 2 weeks. The second case concerns to the development of papular and patch granuloma annulare in a 58‐year‐old white woman 2 months after the second dose of hepatitis B vaccine. To the best of our knowledge, only a few paediatric and adult cases of lichen planus as a complication of hepatitis B vaccination have been reported in medical literature so far. This is the second case of granuloma annulare following hepatitis B vaccine. Our report, similar to earlier papers, appears to support the onset of lichen planus and granuloma annulare as a possible rare complication of hepatitis B immunization.

Bedbugs (Cimicidae infestation): the worldwide renaissance of an old partner of human kind

Bedbugs have been known as a human parasite for thousands of years, but scientific studies about this insect are recent and limited. Cimex lectularius, the common bedbug, was a well-known parasite in human dwellings until the end of the Second World War. Nowadays, bedbugs are considered uncommon in the industrialized world. Anecdotal reports suggest that bedbugs are getting more common in the United States, Canada, and United Kingdom. In Brazil, there are few reports about bedbug infestations in the literature. The aim of this article was to alert physicians, especially in Brazil, about this ectoparasitosis, including aspects of the bedbug biology, their parasitism in human host, treatment and prophylaxis.

Drug-Induced Hypersensitivity Syndrome Due to Anticonvulsants in a Two-Year-Old Boy

Drug‐induced hypersensitivity syndrome (DIHS) usually refers to severe cutaneous drug eruption associated with systemic involvement and potentially fatal outcome. We report a 2‐year‐old Caucasian boy who developed DIHS due to phenytoin and phenobarbital and who showed extensive internal organ involvement. We are alerting that failure to recognize this drug eruption and discontinue the culprit drug may result in increased severity, greater extent of internal organ involvement, and fatal outcome. The recent research about the influence of human herpesvirus 6 co‐infection on the pathogenesis of DIHS is also discussed by the authors in this paper.

An unusual association between scalp psoriasis and ophiasic alopecia areata: the Renbök phenomenon

The Renbök phenomenon or inverse Köbner phenomenon was originally described by R. Happle et al. in 1991, referring to normal hair growth in psoriatic plaques observed in patients with both alopecia areata and psoriasis. A 39-year-old white woman, with a 20-year history of ophiasic alopecia areata (AA), presented with a 1-year history of erythematous, scaling lesions on her scalp. The patient had never observed any hair regrowth within the scalp areas affected by the AA. She reported a history of rheumatic fever during early childhood, and hypothyroidism at the age of 25 years. In addition, her father had moderate psoriasis, involving the knees, elbows and scalp. Dermatological examination revealed well-defined areas of nonscarring alopecia with an ophiasic pattern affecting the temporal, parietal and occipital regions of the scalp. Moreover, psoriatic plaques with silvery-white scales and positive Auspitz’s sign were seen on the interparietal and parietal areas. Interestingly, the ophiasic area with psoriasis presented completely normal hair growth, with no signs of rarefaction or morphological alterations. The limit zone between psoriasis and the AA lesions on the scalp showed an interface region where both erythematous, white, scaling plaques and AA were evident (Fig. 1a). A punch biopsy of this interface region revealed a typical psoriasiform pattern associated with a reduced number of follicles, with no scarring (Fig. 1b). Laboratory investigations including fasting blood glucose, levels of antithyroid and antinuclear antibodies, thyroid hormones (T3, T4) and thyroid-stimulating hormone, lipid profile and full blood count showed no abnormalities. The Renbök phenomenon has been reported to occur in patients with psoriasis and AA universalis, as well as in patients with AA sparing areas of naevus flammeus on the parietal scalp and AA sparing a congenital melanocytic naevus of the eyebrow. The Renbök phenomenon occurring in psoriasis, sparing areas of ophiasic AA of the scalp, was reported in a patient with Turner’s syndrome in 2003. The pathophysiological mechanism of such phenomena is still unclear. It has been proposed that genetic mosaicism present in congenital naevi might protect against hair loss in the affected regions, whereas in the neighbouring area of these naevi an autoimmune reaction could possibly be eliciting AA. In our patient, it would seem reasonable to propose that cell systems involved in the pathogenesis of psoriasis, including the predominance of memory CD4+ T cells in the dermal plexus, and alterations in the number and distribution of Langerhans cells and phagocytic macrophages in the psoriatic plaques, could induce a therapeutic effect on AA. A similar mechanism is observed after induced, delayed-hypersensitivity reactions to various sensitizers in the treatment of AA, such as diphencyprone and dinitrochlorobenzene. Ganor in 1977 studied the association between AA and psoriasis. Of 5033 patients observed between 1968 and 1975, 407 were diagnosed as having psoriasis and 23 AA. Five of the 23 patients with AA had also psoriasis. We propose that the microenvironment in psoriasis, rich in tumour necrosis factor-a, is not a favourable environment for the development of inflammation seen in AA, therefore inducing the Renbök phenomenon.

Necrobiotic xanthogranuloma with lambda paraproteinemia: case report of successful treatment with melphalan and prednisone.

BACKGROUND : Necrobiotic xanthogranuloma (NXG) is a rare non-X histiocytosis with conspicuous lesions on the periorbital skin. METHODS : A diabetic patient presented with NXG and a previous diagnosis of necrobiosis lipoidica on the legs over a period of almost 2 years before the development of the typical lesions of NXG on the periorbital regions, back, thighs and legs. The patient was found also to have developed lambda paraproteinemia. RESULTS : Treatment with melphalan and prednisone resulted in great improvement of cutaneous lesions and paraproteinemia remission. CONCLUSION : This case report details how melphalan and prednisone can be administered in the successful treatment of necrobiotic xanthogranuloma with lambda paraproteinemia

Micoses superficiais e os elementos da resposta imune

Superficial mycoses are prevalent worldwide. They are often caused by dermatophytes and restricted to the stratum corneum. The hosts immune response against infections caused by dermatophytes basically depends on the hosts defense against metabolites of the fungi, virulence of the infecting strain or species and anatomical site of the infection. We will review some of the factors of the hosts immune defense that influence the efficacy of the immune response. We will particularly review the role of pattern recognition receptors (PRRs), such as toll-like receptors or lectin receptors (DCSIGN and Dectin 2), which participate in the innate immune response, bringing specificity to the immune response and setting its pattern. The predominance of a cellular or humoral immune response determines the clinical manifestations and the prognosis of the infection, leading to healing or chronicity

Urticaria as a Cutaneous Sign of Adult-Onset Still's Disease

Background: The cardinal signs and symptoms of adult-onset Stills disease (AOSD) include periodic fever, arthralgia and arthritis, lymphadenopathy, hepatosplenomegaly, an evanescent rash accompanied by neutrophilic granulocytosis, and a negative rheumatoid factor and antinuclear antibody test. Objective: To alert clinicians and dermatologists to internal diseases such as AOSD when assisting patients with urticarial eruptions and systemic symptoms. Methods: A case report of a 52-year-old white woman who received conventional therapy for urticaria for 3 years, with no improvement. Following this period, a diagnosis of AOSD was performed based on the presence of systemic symptoms. Results: The inflammatory activity markers decreased by the second month of methotrexate therapy; however, the cutaneous lesions failed to disappear. Thalidomide was initiated, and total improvement of the cutaneous lesions was observed after 2 weeks. Conclusion: Urticarial rash is an uncommon presentation of AOSD, and clinicians must be alert to the possibility of a misdiagnosis in these cases.

Reações cutâneas graves adversas a drogas - aspectos relevantes ao diagnóstico e ao tratamento - Parte I - Anafilaxia e reações anafilactóides, eritrodermias e o espectro clínico da síndrome de Stevens-Johnson & necrólise epidérmica tóxica (Doença de Lyell)

Severe Cutaneous Adverse Reactions to drugs (SCARD) generally require hospitalization, and at times in the intensive therapy or burn care unit for observation of the vital signs and the viscera function. The aim of this study is to describe these reactions in order to facilitate recognition and treatment. This group of drug reactions includes anaphylaxis, Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN) and, depending on the systemic involvement, erythroderma. In this article we approach the characteristics and treatment of some adverse reactions to drugs: anaphylaxis, erythroderma, Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN).

The use of nested Polymerase Chain Reaction (nested PCR) for the early diagnosis of Histoplasma capsulatum infection in serum and whole blood of HIV-positive patients*

The aim of the study was to detect the rDNA sequences and their regions in Histoplasma capsulatum, which could be considered species-specific and used as a molecular method for this diagnosis by the technique of nested polymerase chain reaction (nested PCR), employing specific sequences (primers) for H. capsulatum: 18S rDNA region (HC18), 100 kDa (HC100) and the sequence 5.8 S-ITS rDNA (HC5.8). The PCR sequences HC18, HC100 and HC5.8 resulted in a specificity of 100%. The molecular assays may increase the specificity, sensitivity and speed in the diagnosis of Histoplasmosis.