Fabio Francesconi

Dermatophytosis caused by Tricophyton rubrum as an opportunistic infection in patients with Cushing disease.

Trichophyton rubrum is a common agent found in superficial mycoses, which present ample non-inflammatory lesions, with chronic evolution, especially in immunocompromised patients. The hypercortisolism in Cushings syndrome increases the risk of infections as a result of the immunosuppressive effect of glucocorticoids. The reported cases here refer to two different types of dermatophytosis caused by Trichophyton rubrum in patients with Cushings disease, resistant to antifungal treatment. The disease remitted after the levels of cortisol went back to normal.

Lobomycosis: epidemiology, clinical presentation, and management options

Lobomycosis is a subcutaneous mycosis of chronic evolution caused by the Lacazia loboi fungus. Its distribution is almost exclusive in the Americas, and it has a particularly high prevalence in the Amazon basin. Cases of lobomycosis have been reported only in dolphins and humans. Its prevalence is higher among men who are active in the forest, such as rubber tappers, bushmen, miners, and Indian men. It is recognized that the traumatic implantation of the fungus on the skin is the route by which humans acquire this infection. The lesions affect mainly exposed areas such as the auricles and upper and lower limbs and are typically presented as keloid-like lesions. Currently, surgical removal is the therapeutic procedure of choice in initial cases. Despite the existing data and studies to date, the active immune mechanisms in this infection and its involvement in the control or development of lacaziosis have not been fully clarified. In recent years, little progress has been made in the appraisal of the epidemiologic aspects of the disease. So far, we have neither a population-based study nor any evaluation directed to the forest workers.

Use of dermoscopy for diagnosis of exogenous ochronosis

Exogenous ochronosis consists of chronic hyperpigmentation of areas previously treated with topical agents such as hydroquinone, resorcinol, antimalarials and phenol. Early diagnosis allows to promptly suspend the causative agent and it is imperative since the available therapeutic options are scarce and have presented so far unsatisfactory results. Three cases of exogenous ochronosis on the face which were diagnosed with the use of dermoscopy are presented. Dermatoscopy showed blackish-gray amorphous structures, some obliterating the follicular openings. Histopathological examination confirmed the diagnosis.

Learning to love dermatology by caring for the underserved: a field trip into the heart of Amazonia

Instituto de Dermatologia Professor Rubem David Azulay-Santa Casa da Misericordia do Rio de Janeiro, Rio de Janeiro, Brazil, Universidade do Estado do Rio de Brazil, Rio de Janeiro, Brazil, Universidade Gama Filho, Rio de Janeiro, Brazil,, Instituto de Anatomia Patologica Professor Joao Lobato, Santa Casa da Misericordia de Rio do Janeiro, Rio de Janeiro, Brazil, Universidade Federal do Amazonas, Manaus, Brazil, Fundacao de Medicina Tropical, Dr Heitor Vieira Dourado, Manaus, Brazil, Departments of Infectious Diseases, Sao Paulo, Brazil, Legal Medicine, Military Hospital, Sao Paulo, Brazil, and Centro Hospitalar Sistema Penitenciario, Sao Paulo, Brazil, Medical student members of the expedition: Nixon da Silva Pessoa, Ademir Cadorin,Walber Aparecido Costa,Gizelle Ribeiro Alves, Paula Carolina Bombonati, Roniclever Moro E-mail: lunaazulay@gmail.com

Failure of fluconazole in treating cutaneous leishmaniasis caused by Leishmania guyanensis in the Brazilian Amazon: An open, nonrandomized phase 2 trial

Background The treatment of Leishmaniasis caused by Leishmania (Viannia) guyanensis is based on a weak strength of evidence from very few clinical trials and some case series reports. Current treatment guidelines recommend pentamidine isethionate or meglumine antimoniate (Glucantime) as the first-line choices. Both are parenteral drugs with a low therapeutic indexes leading to a high risk of undesired effects. Imidazole derivatives interfere with the production of leishmanial ergosterol, an essential component of their membrane structure. One drug that has been studied in different clinical presentations of Leishmania is fluconazole, a hydrophilic bis-triazole, which is easily absorbed through the oral route with a low toxicity profile and is considered safe for children. This drug is readily available in poor countries with a reasonable cost making it a potential option for treating leishmaniasis. Methods and findings An adaptive nonrandomized clinical trial with sequential groups with dose escalation of oral fluconazole was designed to treat adult men with localized cutaneous leishmaniasis (LCL) in Manaus, Brazil. Eligible participants were patients with LCL with confirmed Leishmania guyanensis infection. Results Twenty adult male patients were treated with 450 mg of fluconazole daily for 30 days. One patient (5%) was cured within 30 days of treatment. Of the 19 failures (95%), 13 developed a worsening of ulcers and six evolved lymphatic spreading of the disease. Planned dose escalation was suspended after the disappointing failure rate during the first stage of the trial. Conclusion/Significance Oral fluconazole, at the dose of 450mg per day, was not efficacious against LCL caused by Leishmania guyanensis in adult men. Trial registration Brazilian Clinical Trial Registration (ReBec)—RBR-8w292w; UTN number—1158-2421

Tunneling island pedicled flap after resection of carcinoma on the face

Carcinomas on the face are prevalent lesions, with potentially serious repercussions from aesthetic, psychological, and functional perspectives. Surgical reconstruction after excision of these lesions is a challenge for the dermatologic surgeon, requiring good knowledge of the anatomy of the face and accurate implementation of the most appropriate method for each case. Among the various reconstructive procedures are skin flaps, of which the island pedicle flap and its variants stand out. The present article demonstrates the use of the island pedicle flap transferred to the surgical defect through a subcutaneous tunnel, showing the application and characteristics of this method. Reconstruction using a tunneling island pedicle flap after the excision of a facial carcinoma showed good aesthetic and functional results, despite the difficult location of the lesions. This type of flap is a good option for facial reconstruction in difficult areas.

Syphilis associated with paretic neurosyphilis mimicking Reiter’s syndrome in HIV-infected patients

HIV/syphilis co-infection is common because both conditions affect similar risk groups. HIV interferes with the natural history of syphilis, which often has atypical clinical features and nervous system involvement in the early stage of disease. We report the case of an HIV-positive patient with secondary syphilis, scaling palmoplantar keratoderma, scrotal eczema, balanitis and urethritis mimicking Reiter’s syndrome. Immunohistochemistry using polyclonal antibodies against Treponema pallidum revealed the presence of spirochetes, associated with the paretic form of parenchymal neurosyphilis. The patient was given crystalline penicillin, with complete resolution of dermatological and neurological symptoms, and no sequelae.

Poorly differentiated synovial sarcoma in the wrist - Case report

Synovial sarcomas are rare malignant tumors affecting mainly young adults, presenting as a slow growth mass located in deep soft tissues of extremities, near the joints. In this report a 34-year-old male patient, presented an ulcerovegetative lesion on the right wrist which was completely excised. Histopathology and immunohistochemistry confirmed synovial sarcomas with poorly differentiated cells. This patient presented 11 months later with ipsilateral axillary lymph node metastasis, which emphasizes the unfavorable prognosis of this synovial sarcoma variant. The indolent growth pattern of this sarcoma justifies the well circumscribed initial stages, which progressively infiltrate adjacent structures with lung metastasis (80%) and lymph node involvement (20%) and thus corroborates the importance of early diagnosis and proper treatment.

A Rapidly Growing Lesion on the Lip—Quiz Case

A 32-year-old Brazilian man infected with human immunodeficiency virus (HIV) presented with a 6-month history of a rapidly growing lesion in his lower and upper lip, associated with weight loss of 12 kg. He reported no history of trauma, tobacco smoking, heavy drinking, or any work that dealt with soil. The patient had always lived in Santarem, a city located in the Amazon region in Brazil. Physical examination revealed an asymptomatic ulcerous vegetating lesion affecting the lower and upper gums and lips (Figure 1 and Figure 2). No regional lymphadenopathy was noticed. A skin biopsy specimen was obtained and stained with hematoxylin-eosin and periodic acid–Schiff (Figure 3). What is your diagnosis?