Omar Lupi

Tropical dermatology: Marine and aquatic dermatology

UNLABELLED Dermatoses caused by marine organisms are frequently seen in dermatology clinics worldwide. Cutaneous injuries after exposure to marine environments include bacterial and fungal infections and lesions caused by aquatic plants and protists. Some of these diseases are well known by dermatologists, such as Vibrio vulnificus septicemia and erysipeloid, but others are uncommon, such as envenomation caused by ingestion or contact with certain dinoflagellates or cyanobacteria, which are associated with rashes that can begin within minutes after exposure. Many marine/aquatic invertebrates, such as sponges, cnidarians, echinoderms, crustaceans, and mollusks, are associated with different kinds of dermatologic lesions that can vary from irritant or allergic contact dermatitis to physical trauma and envenomations. These cutaneous lesions may result in mild local reactions or can be associated with severe systemic reactions. Invertebrate animals, such as cnidarians, sea urchins, and worms, and aquatic vertebrates, such as venomous fishes and stingrays, are commonly associated with skin lesions in many countries, where they can constitute occupational dermatoses among fishermen and scuba divers, but they can also be observed among persons who contact these animals in kitchens or beaches. The presence of unusual lesions, a recent travel history, and/or a report of contact with an aquatic environment (including ownership of a marine or freshwater aquarium) should alert the dermatologist to the etiology of the cutaneous problems. LEARNING OBJECTIVES After completing this learning activity, participants should be able to recognize the cutaneous manifestations of marine/aquatic infections, bites, stings, and wounds, etc., treat the cutaneous manifestations of marine/aquatic injuries, and help prevent marine/aquatic injuries.

Tropical dermatology: Venomous arthropods and human skin Part I. Insecta

Although many tropical insects carry infectious diseases, cutaneous injury can occur by other mechanisms, for example erucism (envenomation by caterpillars) or lepidopterism (dermatitis from moths). Pararama is a unique form of erucism seen in workers in contact with rubber trees in the Amazon, and it is caused by Premolis larvae, resulting in progressive periarticular fibrosis, ankylosis, and the loss of articulation. Ants and aquatic insects of the Belostomatidae family can cause painful bites and stings. Anaphylactic shock and death can result from the venom of bees and wasps. Beetles can cause vesicular dermatitis via cantharidin or paederin. Myiasis results from fly larvae (maggots) feeding on live or necrotic tissue of humans or other hosts, while New World screwworm fly larvae feed only on living tissue and burrow (ie, screw) more deeply when attempts are made to remove them. Tungiasis is characterized by very pruritic and painful papules and ulcers resulting from a Tunga flea penetrating the hosts skin. Dermatologists should be able to diagnose and treat the cutaneous manifestations of these tropical insects and educate their patients on prevention.

Manifestações mucocutâneas da dengue

Dengue fever is a systemic viral disease that occurs epidemically in tropical and subtropical regions of Asia, Americas and Africa. The dengue virus belongs to the genus Flavivirus of the family Flaviviridae (group B arbovirus). Aedes aegypti is the major vector and the true reservoir for the virus. Classic dengue fever lasts for two-five days, with severe headache, intense myalgia, arthralgia and retro-orbital pain. Cutaneous alterations include several findings such as a diffuse morbilliform rash that may be pruritic and heals with desquamation, and minor bleeding phenomena such as epistaxis, petechiae, and gingival bleeding. Diffuse capillary leakage of plasma is responsible for the hemoconcentration and thrombocytopenia that characterize dengue hemorrhagic fever. Cutaneous manifestations of dengue hemorrhagic fever include many disseminated hemorrhagic lesions such as petechiae and ecchymoses, but also hemodynamic instability with filiform pulse, narrowing of pulse pressure, cold extremities, mental confusion, and shock.

Tropical dermatology: Venomous arthropods and human skin: Part II. Diplopoda, Chilopoda, and Arachnida

Members of arthropod classes Chilopoda (centipedes), Diplopoda (millipedes), and Arachnida (spiders and scorpions) cause tissue injury via bites, stings, and/or a release of toxins. A few members of the Acari subclass of Arachnida (mites and ticks) can transmit a variety of infectious diseases, but this review will cover the noninfectious manifestations of these vectors. Dermatologists should be familiar with the injuries caused by these arthropods in order to initiate proper treatment and recommend effective preventative measures.

Ancient adaptations of human skin: why do we retain sebaceous and apocrine glands?

Human evolution has been characterized by a marked decrease in body hair and an increase in the importance of pigment in the naked epidermis as a shield against the harmful effects of solar radiation. 1 Humans are not hairless and, when we use this term with respect to humans, it means the lack of a dense layer of thick fur. 1,2 The number and density of hair follicles are similar to those of our nearest primate relatives; the uniqueness of human skin is that human body hair is miniaturized, very fine, and short, and the skin appears to be naked. 2 In addition, human skin contains a special distribution of sudoriparous eccrine glands which, together with the decrease in body hair, creates a very specific thermoregulatory method that allows us to deal very well with high temperatures, even in situations of strenuous physical activity. 1–3

HLA-B27 frequency in a group of patients with psoriatic arthritis

BACKGROUND HLA-B27 is associated with spondyloarthritis, a group of diseases that includes psoriatic arthritis. OBJECTIVES To describe the HLA-B27 frequency in a group of Brazilian patients with psoriatic arthritis and correlate its presence or absence with their clinical manifestations. METHODS Cross-sectional study with 44 psoriatic arthritis patients of a Rheumatology clinic. Demographic and social data were recorded, as were skin and joints clinical examination. HLA-B27 was tested. All data were processed descriptively and comparatively by appropriate software. Parametric and non parametric tests were used with 5% statistical significance. RESULTS HLA-B27 was negative in 32 of the 44 patients (72,7%). Most of them were male, Caucasian, living in Rio de Janeiro, with plaque type psoriasis and average age of 52,9 years. There was statistical significant correlation between positive HLA-B27 and male gender (p=0,004). Negative HLA-B27 had a tendency to correlate with hands and wrists arthritis (p=0,07). There was an inverse significant correlation between HLA values and Schöbers test (p=0,02). CONCLUSION Although HLA-B27 is negative in most of patients, it is significantly associated to male gender and inversely correlated with Schöbers test.

Cutaneous tuberculous gummas in a patient with polymyositis

Metastatic tuberculous abscesses or cutaneous tuberculous gummas occur mostly by reactivation of ancient cutaneous foci and is triggered mainly by pharmacological immunosuppression, diabetes mellitus, alcoholism or acquired immunodeficiency syndrome. The present case report refers to a 33-year-old male patient with polymyositis and a previous diagnosis of treated pulmonary tuberculosis. He presented cutaneous abscesses and fever months after the tuberculosis regimen. The patient was diagnosed as metastatic tuberculous abscesses associated with immunosuppression as result of polymyositis treatment.

Giant primary pleomorphic dermal liposarcoma

To the Editor, Pleomorphic liposarcoma (PLPS) is an uncommon neoplasm, representing at most 5% of all liposarcomas and up to 20% of pleomorphic sarcomas. These heterogeneous mesenchymal neoplasms are relatively uncommon and compromise a broad range of differentiation and are classified histologically according to the mature tissue they resemble, many of which have more than 1 subtype. Gross tumor size can range from 1.5 to 23.0 cm. PLPS is usually located in deep soft tissues, specifically subfascial and intramuscular areas, with ill-defined and/or infiltrative borders. Subcutaneous location and pure skin involvement are rare. We describe a case of a large and pedunculated PLPS with a remarkable vascular pedicle and did a literature review gathering the 12 cases previously reported. A 69-year-old man presented with a 3-year history of an asymptomatic papule on his pre-sternal region. He referred progressive growth of the lesion and weight loss. Physical examination revealed a polypoid and pedunculated mass, with ulcerous-vegetative surface located at the pre-sternal region, measuring 15 cm in maximum dimension (Figure 1A). Large vessels were observed surrounding the mass and connected to its pulsatile peduncle (Figure 1B). Wide local excision was performed. The histopathological examination revealed a pleomorphic cell pattern neoplasm with areas of necrosis (10%), mitotic index 10 (HPF), presence of several atypical mitoses and marked anaplasia. There were several foci of adipocytic differentiation with giant pleomorphic multivacuolated lipoblasts. Tumor cell nuclei were hyperchromatic, scalloped, bizarre and lobulated with prominent nucleoli. Tumor cell cytoplasms were multivacuolated and optically clear, with a unique characteristic lipoblastic appearance (Figure 2A,B). Immunohistochemistry revealed tumor cell positivity for S-100, vimentin, and negativity for CK pool. Clinicopathologic and immunohistochemical features were consistent with a PLPS. It was performed a thorax Computer Tomography (CT) that showed no involvement of deep structures. The patient was referred to the oncology department for tumor staging and to the thoracic surgery department for widening the surgical margins. After 1 year of the primary excision he remains without signs of recurrence. PLPS is a rare, high-grade sarcoma defined by the presence of pleomorphic lipoblasts. PLPS is an often deep-seated, aggressive neoplasm of the late adulthood that occurs predominantly in the limbs, especially the thigh, and may show a wide range of morphologic appearances. Older patients, above 60 years old, non-limb-based situation, and large size (>5 cm) are the most important prognosticators of poor outcome. However, cutaneous and subcutaneous PLs have a behavior quite different from that of their deep counterparts. Local recurrence was relatively uncommon (17%), and none developed distant metastasis, although rare cases of cutaneous PL have metastasized. This contrasts with the 40% to 50% rate of metastasis associated with deep PL. The dermis is an exceedingly rare site for PLPS, with only fifteen cases of primary dermal PLPS previously reported in the literature (Table 1). These tend to grow in an exophytic manner, presenting either as dome-shaped or polypoid lesions. Our patient presented with a bulky pedunculated tumor which originated in the dermis as there was no deep structures involvement. Comparing with the literature review, it is the only primary dermal PLPS located on the chest, the second largest one, and it is the only