Olga Ferreira

Acute hemorrhagic edema of childhood after H1N1 immunization

Acute hemorrhagic edema (AHE) is an uncommon self-limited disorder affecting young children triggered by infection, drugs, or immunization. A 2-year-old boy was observed due to sudden onset of painful and edematous purpuric papular and plaque lesions of the face and upper extremities that started 2 weeks after H1N1 immunization. The patient also developed exuberant edema on the face and dorsum of the hands. Complete blood count, biochemistry, and urinalysis results were normal. Histopathological examination revealed perivascular and periadnexial lymphocytic infiltrate with neutrophils and eosinophils, and leukocytoclastic vasculitis. Blood PCR technique was negative to several viruses, namely adenovirus, cytomegalovirus, Epstein Barr, enterovirus, HHV6, parvovirus B19, and H1N1. Symptomatic treatment and parents reassurance was promptly provided. However, new lesions continued to develop and in this setting systemic corticosteroid was prescribed. Complete clinical resolution was achieved within 2 weeks and no relapse was observed. The temporal relationship with H1N1 immunization, absence of previous drug intake, as well as exclusion of viral infections led the authors to propose that H1N1 vaccine was the predisposing factor in AHE development in our patient. To our best knowledge, this is the first reported association between AHE and H1N1 immunization.

Multilocal Programming and Applications

Multilocal programming aims to identify all local maximizers of unconstrained or constrained nonlinear optimization problems. The multilocal programming theory relies on global optimization strategies combined with simple ideas that are inspired in deflection or stretching techniques to avoid convergence to the already detected local maximizers. The most used methods to solve this type of problems are based on stochastic procedures. In general, population-based methods are computationally expensive but rather reliable in identifying all local solutions. Stochastic methods based on point-to-point strategies are faster to identify the global solution, but sometimes are not able to identify all the optimal solutions of the problem. To handle the constraints of the problem, some penalty strategies are proposed. A well-known set of test problems is used to assess the performance of the algorithms. In this chapter, a review on recent techniques for both unconstrained and constrained multilocal programming is presented. Some real-world multilocal programming problems based on chemical engineering process design applications are described.

Severe onychodystrophy caused by allergic contact dermatitis to acrylates in artificial nails

Acrylic resin monomers, especially acrylates and methacrylates, are well-known sensitizers responsible for allergic contact dermatitis mainly in the occupational setting. The most frequently affected professionals are dentists, orthopedic surgeons, manicurists, painting industry and fiberglass workers. The authors report the case of a 39-year-old healthy woman, a secretary, who developed severe onychodystrophy of all fingers, 1 week after the application of sculptured acrylic nails.

Erythema multiforme-like lesions revealing allergic contact dermatitis to exotic woods

We report a 45-year old man who developed maculopapular exanthema on the inferior cervical folder, axillae and umbilicus, as well as erythema multiforme-like lesions on the wrists after the introduction in his work of pao ferro (Machaerium scleroxylon). Patch tests were positive to pao ferro and ebony. This case highlights the importance of patch tests for the confirmation of the culprit agent in occupational dermatoses and also to identify other occupational allergens that the patient should avoid. Tropical woods contain quinones that could explain the possible cross-reactions between woods belonging to different families.

Herp zoster at the site of infliximab infusion: case report.

Worldwide, many patients have been treated with tumor necrosis factor-α (TNF-α) antagonists for indications that include chronic inflammatory diseases such as rheumatoid and psoriatic arthritis, inflammatory bowel disease and others. Since their approval, concerns regarding safety have been raised. Increased susceptibility to bacterial infections, especially due to intracellular bacteria like Mycobacterium tuberculosis that is responsible for the most serious complications associated with this treatment. Viral infections are less frequently reported but probably relatively common, representing an important cause of morbidity to remember. Varicella zoster virus is one of the most frequently implicated viruses. We present the case of a 20-year-old man with Crohn’s disease under infliximab treatment who developed herpes zoster at the site of infliximab’s 7th and 9th infusion.

Symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) induced by telmisartan–hydrochlorothiazide

Symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) is a drug-related eruption that characteristically involves the intertriginous or flexural folds and gluteal areas. We report the case of a 48-year-old woman with the presence of a sharply demarcated erythema of the inferior cervical folds, axillae, and gluteal area that started 4 days after the introduction of telmisartan–hydrochlorothiazide administration to treat hypertension. Skin biopsy revealed a dense perivascular and periadnexal lymphohistiocytic infiltrate in the superficial dermis, with some eosinophils and mast cells. A cutaneous drug adverse reaction was suspected, administration of telmisartan–hydrochlorothiazide was suspended, and medium-potency topical corticosteroids were prescribed, with subsequent significant improvement of the lesions. Eight months later, epicutaneous patch tests were performed in previously lesional and nonlesional skin. To the best of our knowledge, this is the first case of SDRIFE related to telmisartan–hydrochlorothiazide and illustrates an uncommon presentation of a skin-related drug reaction to an antihypertensive medication and the role of the dermatologist in diagnosis and management, in particular in follow-up of the patient.

Understanding the cation specific effects on the aqueous solubility of amino acids: from mono to polyvalent cations

The interactions established by mono and polyvalent cations in natural media have important implications on the structure formation, function and physico-chemical behavior of biomolecules, playing therefore a critical role in biochemical processes. In order to further elucidate the molecular phenomena behind the cation specific effects in biological environments, and clarify the influence of the charge of the ions, solubility measurements and molecular dynamics simulations were performed for aqueous solutions of three amino acids (alanine, valine and isoleucine), in the presence of a series of inorganic salts comprising mono-, di- and trivalent cations (LiCl, Li2SO4, K2SO4, CaCl2, AlCl3 and Al2(SO4)3). The evidence gathered indicates that the mechanism by which (salting-in inducing) polyvalent cations affect the solubility of amino acids in aqueous solutions is different from that of monovalent cations. A consistent and refined molecular description of the effect of the cation on the solubility of amino acids based on specific interactions of the cations with the negatively charged moieties of the biomolecules is here proposed.

Primary Langerhans cell histiocytosis of the vulva: acitretin as a glucocorticoid-sparing agent

Serra Kayac etin, MD Ankara Numune Education and Research Hospital Pathology Clinic Ankara Turkey E-mail: seraycakmak@gmail.com References 1 Speeckaert MM, Speeckaert R, Lambert J, et al. Acute generalized exanthematous pustulosis: an overview of the clinical, immunological and diagnostic concepts. Eur J Dermatol 2010; 20: 425–433. 2 Guevara-Gutierrez E, Uribe-Jimenez E, Diaz-Canchola M, et al. Acute generalized exanthematous pustulosis: report of 12 cases and literature review. Int J Dermatol 2009; 48: 253–258. 3 Mayo-Pamp ın E, Fl orez A, Feal C, et al. Acute generalized exanthematous pustulosis due to pseudoephedrine with positive patch test. Acta Derm Venereol 2006; 86: 542– 543. 4 Treudler R, Grunewald S, Gebhardt C, et al. Prolonged course of acute generalized exanthematous pustulosis with liver involvement due to sensitization to amoxicillin and paracetamol. Acta Derm Venereol 2009; 89: 314–315. 5 Sim HS, Seol JE, Chun JS, et al. Acute localized exanthematous pustulosis on the face. Ann Dermatol 2001; 23: S368–S370. 6 Betto P, Germi L, Bonoldi E, et al. Acute localized exanthematous pustulosis (ALEP) caused by amoxicillinclavulanic acid. Int J Dermatol 2008; 47: 295–296.

Necrobiotic xanthogranuloma with giant cell hepatitis, successfully treated with intravenous immunoglobulins

A 44-year-old Caucasian woman with a year history of IgG kappa light-chain monoclonal gammopathy and giant cell hepatitis was referred to our department due to an arm lesion evolving for 2 months. On physical examination, an asymptomatic, erythematous-violaceous indurated plaque on the extensor surface of the left arm (Fig. 1A) and multiple yellowish, nontender, edematous, confluent papules on the periorbital area (Fig. 1B) were observed. The patient complained of recurrent red eye episodes and myalgia. Laboratory tests revealed elevation of transaminases and complement consumption; protein electrophoresis showed a diffuse increase in gamma globulins and a peak of free kappa light-chains; echocardiography was normal. Biopsies of the arm and periorbital lesions showed similar features, namely an infiltrate of histiocytes, including some multinucleated giant and foamy cells, extending into the hypodermis, foci of necrobiosis, cholesterol clefts, and a moderate lymphocytic infiltrate with occasional plasma cells (Fig. 1C–E). The diagnosis of necrobiotic xanthogranuloma (NXG) was established. Liver biopsy revealed hepatocytes with giant cell transformation, microvesicular steatosis, and intralobular necroinflammatory lesions. A bone marrow biopsy excluded a malignancy. Oral prednisolone (1 mg/kg/day) was started and later tapered off and replaced by oral budesonide (9 mg/day), yielding an initial reduction in transaminases values, but followed by another raising (ALT/AST 159/466, normal range <31 U/I). The cutaneous picture worsened increasingly with periorbital necrosis and ulceration (Fig. 2A). As the patient wanted to get pregnant, intravenous immunoglobulins (IVIg), 0.5 g/kg/day (4 consecutive days every 4 weeks) were administered concomitantly with oral budesonide. After three cycles of IVIg, the skin lesions improved remarkably (Fig. 2B) and transaminase values normalized. When 15 cycles of IVIg have been completed, the interval was extended to 6 weeks, maintaining the outcome. An attempt to reduce budesonide to 6 mg/day was followed by elevation of transaminases, leading to a return to the original dose. The serum free kappa light-chains remained Address correspondence and reprint requests to: Ana Filipa Bastos Pedrosa, MD, Department of Dermatology and Venereology, Centro Hospitalar São João EPE, Alameda Prof. Hernani Monteiro, Porto 4200-319, Portugal, or email: anabastospedrosa@gmail.com.

Docetaxel-induced acral erythema and nail changes distributed to photoexposed areas

Docetaxel is a semisynthetic taxane used in the treatment of several malignancies. A 60-year-old male patient suffering from a non–small cell lung cancer with bone metastasis was under treatment with docetaxel and developed acral erythema involving photoexposed areas. Onycholysis and melanonychia were also observed. Drug-induced acral erythema usually involves the palms and soles, but it may occur in more atypical areas such as the backs of the hands and feet and also the face, as occurred in this patient. The nail changes are usually observed after several cycles of docetaxel, but tend to resolve gradually over several weeks despite continued treatment. Early recognition of skin and nail changes in the setting of docetaxel treatment, especially with an unusual presentation, is of paramount importance not only for patient reassurance, but also to avoid unnecessary withdrawal of drug treatment.