Vanessa Santos Cunha

Cutaneous Cryptococccosis Due to Cryptococcus gattii in Immunocompetent Hosts: Case Report and Review

Cutaneous cryptococcosis caused by C. gattii, in immunocompent patients is a rare manifestation of disease, and may be one of the first manifestations of disseminated cryptococcosis. We report a case of disseminated cryptococcosis caused by Cryptococcus gattii presenting as cutaneous lesions in an immunocompetent patient. Previously to our report, only five cases of cutaneous involvement by Cryptococcus gattii in immunocompetent patients have been reported in the literature. Risk factors for C. gattii infection included exposure to the eucalypt reservoirs in tropical and subtropical areas. Skin involvement corresponded to the disseminated form of cryptococcosis in the majority of patients, and commonly affected the face and neck with different morphologies including papules, pustules, plaques, ulcers, subcutaneous masses, cellulitis or acneiform lesions. Due to the severity of this infection and the life threatening condition that it represents, clinicians must be aware that cutaneous involvement may be one of the first manifestations of disseminated cryptococcosis caused by C. gattii especially in patients living and coming from endemic areas.

Two specific strains of Histoplasma capsulatum causing mucocutaneous manifestations of histoplasmosis: preliminary analysis of a frequent manifestation of histoplasmosis in southern Brazil.

ObjectivesSkin lesions, uncommon in US cases (<10%), occur in 38–85% of cases reported from Latin America. Although these differences may reflect reporting bias, delayed diagnosis, or differences in host immune response among different ethnic groups, they also could result from genetic differences changing the pathobiology of the organism. It is possible that genetic differences among strains of H. capsulatum may influence the pathogenesis and clinical manifestations of histoplasmosis.MethodsWe examined the clinical features of patients with mucocutaneous manifestations of histoplasmosis and performed genetic analysis based on nucleotide sequence variations in the internal transcribed spacer regions of rRNA genes of H. capsulatum isolates of patients. Two pairs of PCR primers were designed to develop and amplify the ITS regions of H.xa0capsulatum, 5′-TACCCGGCCACCCTTGTCTA-3′ and 5′-AGCGGGTGGCAAAGCCC-3′. These primers were based on the ITS sequence of Ajellomyces capsulatus, the ascomycetous teleomorph form of H.xa0capsulatum, deposited in the GenBank (accession number U18363). Eight patients attending a tertiary-care hospital in southern Brazil were enrolled into the study. All case patients had skin cultures growing H. capsulatum at the mycology laboratory.ResultsSix of eight (75%) patients were HIV-positive and presented involvement of multiples organs by H. capsulatum. Two HIV-negative patients did not present evidence of involvement of other organs besides mucosa and skin. ITS sequencing of a DNA H. capsulatum fragment of 485-bp from isolates of 8 patients revealed two distinct strains. The 2 distinct fragments (Hc1, Hc2) differed from each other at 7 positions in the ITS regions. They were identical to strains of H. capsulatum isolated in patients from Colombia and Argentina, but different from strains isolated in US. Hc1 and Hc2 were isolated in 5 patients and 3 patients, respectively, with mucocutaneous manifestations of histoplasmosis. Both Hc1 and Hc2 strains were isolated in HIV-infected and non-HIV-infected patients.ConclusionsMucocutaneous manifestations of histoplasmosis, which are frequently seen in Brazilian patients were caused by 2 specific strains in our institution. Those strains have been isolated in patients with these particular clinical features of histoplasmosis in Latin America. Our study suggests that unique pathogenic characteristics among the Latin American species of H. capsulatum might explain its increased dermatotropism.

Riga-Fede-Like Disease in an AIDS Patient

Riga-Fede disease is a benign and ulcerative process that occurs as a result of repetitive trauma of the oral mucosal surfaces by the teeth. The authors describe here a case of a 40-year-old man in rescue therapy for advanced AIDS with a 2-month history of an ulcerated area on the dorsal surface of his tongue, which was histopathologically consistent with Riga-Fede disease. This case report is unique because it is the first time that this lesion has been reported in an AIDS patient, and Riga-Fede disease should be included in the differential diagnosis of a tongue ulcer in these populations.

Cytomegalovirus in an AIDS patient

A 41-year-old woman with advanced HIV infection (CD4 cell count of 4 cells per μL) was admitted at our hospital with an ulcer on the central area of the tongue’s dorsal surface that started 1 week before (fi gure, A). She had fever, weight loss, and a recent diagnosis of histoplasmosis of the lymph nodes that was being treated with oral itraconazole. At the examination, the tongue was tender and the ulceration was involved by atrophy and elongated fi liform papillae that are typical of a hairy tongue, with a dark colour secondary to porphyrin pigment deposition by bacterial metabolism. A biopsy of the ulcer showed minimal epidermal changes and an “owl’s eye” appearance of the endothelial cells, which is pathognomonic for cytomegalovirus infection. The biopsy was negative for Histoplasma capsulatum organisms. No other site was aff ected by cytomegalovirus. Intravenous ganciclovir for 14 days was started with complete regression of the tongue ulcer (fi gure, B). The patient was started on antiretroviral treatment (stavudine, lamivudine, and efavirenz) and, as of February, 2006, she was asymptomatic, with a CD4 cell count of 208 cells per μL and a viral load of less than 50 copies per mL. She has had no further cytomegalovirusrelated complications. In patients with advanced AIDS, cytomegalovirus is a frequent cause of chorioretinitis, oesophagitis, pneumonitis, and chronic perineal ulcerations. It has also been involved in endocrine, bone marrow, central nervous system, and kidney abnormalities. Cutaneous manifestations are often atypical and range from vesicles to nodules and chronic ulcerations, but rarely aff ect the tongue. However, tongue involvement in advanced AIDS is common. The tongue is aff ected by local rather than systemic pathologies and a large number of concomitant lesions are often present. The most common lesions are candidosis, hairy leucoplakia, non-specifi c chronic glossitis, melanotic pigmentation, and herpes simplex infection. Fortunately, mucocutaneous lesions associated with cytomegalovirus or other herpesvirus infection respond well to systemic antiviral therapy but are diffi cult to diff erentiate from other ulcerogenic diseases—eg, aphthous major, necrotising stomatitis, and other unspecifi ed ulcerations—without biopsy and histopathological examination. Cytomegalovirus in an AIDS patient

EXPERIMENTAL DERMATOLOGICAL SURGERY: AN ANIMAL MODEL FOR DEVELOPING SKILLS WITH DERMAL FILLERS

The importance of laboratory experiments in the formation of physicians is well recognized since they facilitate scientific development and enhance technical skills. Dermal filling procedures are performed for the correction of wrinkles, rhytids, scars, and lipodystrophy. Till date, experimental models for the training of dermal filling techniques have not been studied. To demonstrate an experimental laboratory model for the training of dermal filling techniques in an animal model. The heads of pigs were used for this purpose, together with Carbopol gel at different densities, which was used to simulate the fillers available in the market. Needles and specific cannulas were used to apply the fillers into the creases and other areas of the pig skin. The pig head appears to be a suitable model for this training. Carbopol gel is a good choice for simulating fillers. This model of laboratory experiment requires a minimum of infrastructure; it is a low-cost alternative and facilitates practical training in the application of dermal fillers.