Norma Tiraboschi Foss

Chronic phlebopathic cutaneous ulcer: a therapeutic proposal.

The Correspondence Section serves as a forum for opinion exchange about subjects of general interest such as dermatologic training, relations between dermatologists and pharmaceutical houses, governmental control of dermatology and medical practice in general, peculiarities of dermatology related to geographic, climatic, or racial factors, the ̄ow of information and publications, as well as other concerns the readership might have. Contributions are welcome and should conform to the usual format for correspondence. Manuscripts will undergo standard editorial procedures. Submit all correspondence to Roberto CorteÂs Franco, MD, Fax: +52 (5) 665 7691. E-mail: cortesmd@prodigy.net.mx

Role of Ulnar Nerve Sonography in Leprosy Neuropathy With Electrophysiologic Correlation

Objective. The purpose of this study was to evaluate the diagnostic usefulness of ulnar nerve sonography in leprosy neuropathy with electrophysiologic correlation. Methods. Twenty‐one consecutive patients with leprosy (12 men and 9 women; mean age ± SD, 47.7 ± 17.2 years) and 20 control participants (14 men and 6 women; mean age, 46.5 ± 16.2 years) were evaluated with sonography. Leprosy diagnosis was established on the basis of clinical, bacteriologic, and histopathologic criteria. The reference standard for ulnar neuropathy in this study was clinical symptoms in patients with proven leprosy. The sonographic cross‐sectional areas (CSAs) of the ulnar nerve in 3 different regions were obtained. Statistical analyses included Student t tests and receiver operating characteristic curve analysis. Results. The CSAs of the ulnar nerve were significantly larger in the leprosy group than the control group for all regions (P < .01). Sonographic abnormalities in leprosy nerves included focal thickening (90.5%), hypoechoic areas (81%), loss of the fascicular pattern (33.3%), and focal hyperechoic areas (4.7%). Receiver operating characteristic curve analysis showed that a maximum CSA cutoff value of 9.8 mm2 was the best discriminator (sensitivity, 0.91; specificity, 0.90). Three patients with normal electrophysiologic findings had abnormal sonographic findings. Two patients had normal sonographic findings, of which 1 had abnormal electrophysiologic findings, and the other refused electrophysiologic testing. Conclusions. Sonography and electrophysiology were complementary for identifying ulnar nerve neuropathy in patients with leprosy, with clinical symptoms as the reference standard. This reinforces the role of sonography in the investigation of leprosy ulnar neuropathy.

Differential correlation between interleukin patterns in disseminated and chronic human paracoccidioidomycosis

In an attempt to understand better the immunoregulatory disorders in paracoccidioidomycosis (PCM), the possible correlation between interleukin pattern, lymphoproliferation, C‐reactive protein (CRP) and specific antibody levels was investigated in the polarized clinical forms of this disease. We studied 16 PCM patients, eight with the disseminated disease (four under treatment and four non‐treated) and eight with the chronic disease. The patients with disseminated disease exhibited high antibody titres specific to Paracoccididoides brasiliensis antigen compared with patients with the chronic form of disease. Tumour necrosis factor (TNF), IL‐1, IL‐6 and CRP in the serum of non‐treated disseminated PCM patients were increased, which correlated positively with the low mitogenic response of peripheral blood mononuclear cells (PBMC) to phytohaemagglutinin (PHA) (P < 0·01) and with the high antibody titres (P < 0·001) of these patients. Moreover, we found in the disseminated PCM patients positive correlations between IL‐1 and IL‐6 (P = 0·0007); IL‐1 and TNF (P = 0·0045); IL‐1 and IL‐6 with the high antibody titres (P = 0·0834 and P = 0·0631, respectively); IL‐1, IL‐6 and TNF with CRP levels. By contrast, no correlations were found with those interleukins in the treated disseminated and chronic patients or in controls. It was interesting to find an inverse correlation between IL‐4 and antibody production in non‐treated disseminated PCM (r = −0·4770); moreover, a significant correlation (P = 0·0820) was found in chronic PCM patients with respect to the low level of either IL‐4 and antibody titres against fungus antigen. Chronic PCM patients also had IL‐2 levels inversely correlated with antibody production (r = −0·6313; P = 0·0628). Inverse correlations were also observed between IL‐2 and IL‐6 levels in non‐treated disseminated patients (P = 0·0501) and between IL‐2 and IL‐4 in chronic patients (P = 0·0131). The inflammatory cytokines might have a pivotal role in the genesis and in control of some aspects of the disease, such as granulomatous reaction, hypergammaglobulinaemia and depression of T cell‐mediated immunity in PCM.

Úlcera de perna: um estudo de casos em Juiz de Fora-MG (Brasil) e região

BACKGROUND: Leg ulcers are characterized as tissue loss in the lower extremities, generally caused by vascular dysfunction. OBJECTIVES: Verify the clinical and epidemiological profiles of the population sample with leg ulcers treated at the health centers of Juiz de Fora (Brazil). MATERIAL AND METHODS: 124 leg-wound patients were evaluated between January 1999 and August 2001 and submitted to a clinical protocol. RESULTS: The mean age was 64 years, with females in the majority (65.3%). The mean family composition was 3.7 persons, and family income was around US

Dermatoses em pacientes com diabetes mellitus

200.00 (86.8%). Venous insufficiency (90.3%), systemic arterial hypertension (54%), obesity (20.2%) and diabetes mellitus (16.1%) were the most frequent events associated with the ulcers. An association of venous insufficiency and arterial hypertension was frequent in 43.7% of the sample, and significant (p<0.01) to predisposition to the ulcers. These were classified as venous (79%), hypertensive (15.4%), mixed and other (5.6%). The ulcers were generally localized in the distal third of legs (90%) and considered large (5 cm) in about 90% of the sample, with means of 8.7 cm and 9.6 cm to vertical and horizontal axes, respectively. The ulcers were accompanied mainly by hyperpigmentation (92.7%), lipodermatosclerosis (68.5%) and varicose veins (66.9%), with a mean duration of 94.2 months and 50% of them recurrent. CONCLUSIONS: The data suggested that leg ulcer is an important chronic disease in the elderly and poor population of Juiz de Fora and region.

Dipstick assay to identify leprosy patients who have an increased risk of relapse

OBJECTIVE It is yet unknown the relationship between diabetes and determinants or triggering factors of skin lesions in diabetic patients. The purpose of the present study was to investigate the presence of unreported skin lesions in diabetic patients and their relationship with metabolic control of diabetes. METHODS A total of 403 diabetic patients, 31% type 1 and 69% type 2, underwent dermatological examination in an outpatient clinic of a university hospital. The endocrine-metabolic evaluation was carried out by an endocrinologist followed by the dermatological evaluation by a dermatologist. The metabolic control of 136 patients was evaluated using glycated hemoglobin. RESULTS High number of dermophytosis (82.6%) followed by different types of skin lesions such as acne and actinic degeneration (66.7%), pyoderma (5%), cutaneous tumors (3%) and necrobiosis lipoidic (1%) were found. Among the most common skin lesions in diabetic patients, confirmed by histopathology, there were seen necrobiosis lipoidic (2 cases, 0.4%), diabetic dermopathy (5 cases, 1.2%) and foot ulcerations (3 cases, 0.7%). Glycated hemoglobin was 7.2% in both type 1 and 2 patients with adequate metabolic control and 11.9% and 12.7% in type 1 and 2 diabetic patients, respectively, with inadequate metabolic controls. A higher prevalence of dermatophytoses was seen in the both groups with inadequate metabolic control. CONCLUSIONS The results showed a high prevalence of skin lesions in diabetic patients, especially dermatophytoses. Thus, poor metabolic control of diabetes increases patients susceptibility to skin infections.

Disseminated mucocutaneous leishmaniasis resulting from chronic use of corticosteroid

Classification of leprosy patients into paucibacillary (PB) and multibacillary (MB) determines the duration of treatment; misclassification increases the risk of relapse because of insufficient treatment if an MB patient is classified as PB. We explored the possibility of using a simple dipstick assay based on the detection of antibodies to the Mycobacterium leprae‐specific phenolic glycolipid‐I (PGL‐I) as a tool for classification of patients into PB and MB for treatment purposes. The sensitivity of the dipstick test for detection of MB patients was 85.1%, the specificity 77.7%. We found that of the 71 dipstick negative PB patients 25 (35.2%) were clinically cured at the end of treatment, compared with only two (9.5%) of the 21 dipstick positive PB patients. Of 170 patients in the study population, nine (5.3%) relapsed within the 5‐year follow‐up period. Seven were MB patients, all dipstick positive. Two PB patients relapsed, one was dipstick negative and one was dipstick positive. Dipstick positivity is a risk factor for the future development of relapses, especially in those groups of patients who had received a shorter‐than‐usual course of treatment and the dipstick can be used as an additional, simple tool for classification of patients and for identification of those patients who have an increased risk of relapse.

Generalized cutaneous leishmaniasis in acquired immunodeficiency syndrome

Mucocutaneous leishmaniasis is a granulomatous disease clinically characterized by ulcerated skin and mucosal lesions whose clinical manifestations can regress spontaneously, but with possible long subclinical evolution. The course of the disease is often related to the host immune response. The purpose of this article is to describe the clinical and microscopic findings of cutaneous and mucosal lesions of mucocutaneous leishmaniasis in a patient who presented an unusual form of the disease associated with an immunosuppressive state.

Production of transforming growth factor-beta 1 (TGF-β1) by blood monocytes from patients with different clinical forms of leprosy.

BACKGROUND Leishmaniasis associated with HIV/AIDS has been reported in the last decade. CASE REPORT A case of generalized cutaneous leishmaniasis in a patient with AIDS is described. The case is paradoxical in that the cutaneous lesions resemble anergic leishmaniasis caused by Leishmania (L.) amazonensis and Jorge Lobos disease, but the positive Montenegro test and the clinical improvement with antimonial are more commonly observed in leishmaniasis caused by L.(V.) braziliensis. COMMENT The immunosuppression due to HIV/AIDS seen in this patient may explain the dissemination of the lesions, but the positive specific response to leishmanial antigen may explain the good response to the antimonial treatment.

In Vitro TNF‐α and IL‐6 Production by Adherent Peripheral Blood Mononuclear Cells Obtained from Type 1 and Type 2 Diabetic Patients Evaluated according to the Metabolic Control

In the present study, the concentration of TGF‐β1 secreted by adherent cells isolated from human peripheral blood mononuclear cells (PBMC) and either stimulated with PGL‐1 or lipopolysaccharide (LPS) or left unstimulated was determined by ELISA. The cells were isolated from untreated patients with different clinical forms of leprosy and healthy individuals. The adherent cells exhibited spontaneous release of TGF‐β1 in all clinical forms of leprosy and in healthy individuals; however, lepromatous leprosy/borderline leprosy (LL/BL) patients presenting erythema nodosum leprosum (ENL) displayed significantly higher concentrations of TGF‐β1 than either the other patients studied or the controls. These high TGF‐β1 levels were consistently observed when LL/BL ENL cells were stimulated with phenolic glycolipid (PGL‐1) or LPS, and even in the absence of a stimulus (P < 0·01). The most significant differences in TGF‐β1 levels were observed when comparing the results in the presence of PGL‐1 from ENL with, in order of significance: tuberculoid leprosy (TT) patients (P < 0·001), LL/BL patients without ENL (P < 0·01), healthy individuals (P < 0·01) and borderline‐borderline/borderline‐tuberculoid (BB/BT) patients with reversal reaction (RR) (P < 0·01). The BB/BT patients produced equivalent levels of TGF‐β1 compared with LL/BL patients without ENL, for all types of stimuli (P > 0·05). In contrast, TT patients produced the lowest levels of TGF‐β1 among all the subjects studied (both patients and healthy controls), especially following PGL‐1 stimulation (P < 0·001, and P < 0·05, respectively). In conjunction with our previous data regarding TGF‐β1 expression in dermal lesions, it appears that TGF‐β1 probably plays different roles in leprosy: (i) to mediate a suppressive action locally, associated with the presence of PGL‐1, and (ii) to induce proinflammatory effects when secreted systemically by monocytes, thereby acting as a modulatory cytokine in the acute inflammatory reactions of ENL and associated with the Th2 immune response in multibacillary forms of leprosy.