Walter Belda

Topical Application of Imiquimod as a Treatment for Chromoblastomycosis

Chromoblastomycosis is a subcutaneous mycosis that remains a therapeutic challenge, with no standard treatment and high rates of relapse. On the basis of our recent discoveries in mouse models, we tested the efficacy of topical applications of imiquimod to treat patients afflicted with this chronic fungal infection. We report results of treatment for the first 4 recipients of topical imiquimod, all of whom displayed a marked improvement of their lesions, both with and without concurrent oral antifungal therapy.

Nail Matrix Phenolization for Treatment of Ingrowing Nail: Technique Report and Recurrence Rate of 267 Surgeries

The great toe was disinfected with alcohol 701. Distal block anesthesia was performed, infiltrating 2 mL of lidocaine 2% without epinephrine, and a tourniquet was applied. All of the granulation tissue was removed using a curette. The lateral nail plate was detached from the lateral and proximal nail fold using a nail elevator. The nail plate was cut down its long axis from its free edge to the nail matrix and then removed using a mosquito forceps using rotational movement. Nail matrix, nail bed, and lateral nail fold were gently curetted. A dry cotton swab was used to keep a bloodless field. The nail matrix and nail bed were rubbed strongly for 2 minutes with a cotton swab soaked in phenol solution 88%. The wound was cleaned with alcohol and dried with sterile gauze. The tourniquet was removed, and the wound was dressed using an antibiotic ointment (Figure 1).

Eumicetoma de grãos pretos por Madurella grisea: registro de dois casos

Two cases of black grains eumycotic mycetoma, occurring on a foot, are reported. Both proceeded from the State of Bahia (Brazil), and in both the etiologic agent was Madurella grisea Mackinnon et al., 1949. The grains structure as well as the micromorphologic characteristics of the fungus in saprophytic life were studied. It is the Authors belief that these observations correspond to the 7th and 8th cases reported in the Brazilian medical literature. The Authors do consider the following Madurella species as nomen dubium or nomina confusa: M. ramiroi, M. oswaldoi, M. bovoi, M. tozeuri, M. mansonii, M. brumpti, M. reynieri, M. americana, M. lackawanna e M. ikedae and the same for Rubromadurella mycetomi. The only valid species must be Madurella mycetomatis McGinnis, 1980 (=Madurella mycetomi Brumpt, 1905) and Madurella grisea Mackinnon et al., 1949. Treatment with itraconazole in both reported cases, for a 3 month duration, did not produce any regression of the lesions, the clinical improvement being meager.Os Autores registram dois casos de eumicetoma de graos pretos, com localizacao podal, procedentes da Bahia, provocados por Madurella grisea Mackinnon et al., 1949. Sao estudadas a estrutura dos graos, bem como as caracteristicas micromorfologicas do fungo em vida saprofitica. Acreditam os Autores que estas observacoes correspondem ao setimo e oitavo casos registrados na literatura do pais, provocadas por este fungo. Os Autores consideram nomen dubium ou nomina confusa as seguintes especies de Madurella: M. ramiroi, M. oswaldoi, M. bovoi, M. tozeuri, M. mansonii, M. brumpti, M. reynieri, M. americana, M. lackawanna e M. ikedae, o mesmo ocorrendo com a chamada Rubromadurella mycetomi. As unicas especies validas sao Madurella mycetomatis McGinnis, 1980 (=Madurella mycetomi Brumpt, 1905) e Madurella grisea Mackinnon et al., 1949. Nos dois casos registrados o tratamento com itraconazol, por um periodo de 3 meses nao fez regredir as lesoes, havendo ligeira melhora clinica.

Livedoid vasculopathy secondary to high levels of lipoprotein(a)

fibrils were found around dermal fibroblasts in the culture with 25% serum (Fig. 2). We repeated these experiments three times and obtained similar results. In the skin, dermal fibroblasts, which are surrounded by dermal matrix, produce ECM including collagen, elastin and other matrix proteins, and also communicate with each other and other cell types such as epidermal keratinocytes, playing an important role in the regulation of skin physiology. Especially in cutaneous wound healing, the property of dermal fibroblasts to produce ECM is much more remarkable than in normal conditions. In vitro, dermal fibroblasts proliferate and synthesize ECM in response to several hormones or growth factors. Dermal fibroblasts grow well in the presence of FBS but are subject to density-dependent inhibition of growth when a confluent monolayer is formed. However, recently we found that post-confluent dermal fibroblasts alone in a special culture condition could form dermal equivalents in a culture dish. Moreover, epidermal growth factor (EGF) and insulin in a post-confluent culture of dermal fibroblasts alone produced a dermis-like tissue. In a preliminary study, we found that without serum EGF and insulin we could not induce a dermis-like tissue. Thus, in this study we hypothesized that serum may play an important role in the formation of a dermal equivalent. As a result, a high concentration of serum alone without exogenous materials produced a threedimensional tissue. Macroscopically and microscopically, the three-dimensional tissue induced by a high concentration of serum showed some features that were similar to those of normal human dermis in vivo. In addition, a dermis-like tissue was supported by immunohistochemical and ultrastructural studies. Serum is one of the most important factors that affect the growth and synthetic activities of cells. It is known to stimulate collagen production by fibroblasts. Serum is a mixture of numerous substances. The substances in the serum may together influence cell growth and ECM synthesis of dermal fibroblasts, resulting in the formation of the dermal matrix. Our results showed that a dermal equivalent could be formed by culturing dermal fibroblasts alone with a high concentration of serum, suggesting that serum plays an important role in the formation of a dermal equivalent without exogenous materials. Further study is necessary to evaluate what components in the serum are important for the formation of ECM. In addition, in order to prepare a xenobiotic-free substitute human serum will be necessary instead of FBS.

Extensive long-standing chromomycosis due to Fonsecaea pedrosoi: Three cases with relevant improvement under voriconazole therapy

Abstract Objective: To evaluate voriconazole in the treatment of extensive cases of chromomycosis. Chromomycosis is a chronic infection, which is extremely difficult to eradicate, and is caused by dematiaceous (dark-colored) fungi which affect the skin and subcutaneous tissues, with Fonsecaea pedrosoi being the major etiologic agent. Drugs such as itraconazole, terbinafine, posaconazole and amphotericin B have been employed with variable results. Methods: We treated three Caucasian male patients (ages 44, 57 and 77 years), two were farmers and one a trash collector, with long-standing (20, 10 and 21 years of disease, respectively) and extensive chromomycosis (one lower limb affected, at least) due to Fonsecaea pedrosoi. All patients had received previous therapy with the formerly indicated drugs itraconazole and terbinafine for several months either without or with incomplete response. After that, we started treatment with voriconazole per os 200 mg twice a day. Results: The patients were treated with voriconazole for 12 months until there was clinical and mycological improvement. Clinical response was evident after 30–50 days. One patient developed visual abnormalities and tremors, and the voriconazole was reduced to 200 mg/day without impairment of the clinical and mycological response. The same patient presented photosensitive dermatitis after 12 months of therapy and the voriconazole was stopped. All patients showed elevations of serum gamma-glutamyl transpeptidase (GGT) during the treatment without clinical relevance. Moreover, our three patients obtained partial response with this therapy. Conclusions: This is the first report with a case series of chromomycosis treated with voriconazole. Despite its high cost, voriconazole is a safe and possibly promising drug for use on extensive chromomycosis refractory to conventional treatment.

Treatment of genital warts in men with potassium hydroxide.

SIR, Genital human papillomavirus infection is highly prevalent in sexually active young men. Therapies for genital warts are generally recommended based on considerations of efficacy, adverse events, cost and recurrence rates. Potassium hydroxide (KOH) is a strong alkali that has been found to be effective, safe and well tolerated in the treatment of molluscum contagiosum in children, due to its ability to dissolve keratin and deeply penetrate the skin. We report a study evaluating the safety and efficacy of patient-applied 5% KOH for the treatment of genital warts in sexually active men. This prospective, open-label study was approved by the University of São Paulo General Hospital Institutional Review Board. All patients signed an informed consent form. Male patients over 18 years with one or more genital warts and without any treatment during the last 3 months were included in this trial. Exclusion criteria were urethral or perianal lesions, and giant condylomata. Patients with immunosuppression, a positive serology for human immunodeficiency virus, syphilis or active hepatitis B or C were also excluded. Patients were taught how to apply a KOH 5% aqueous solution on every single lesion using a toothpick with cotton wrapped around the tip. They were further instructed to use the medication once daily until mild inflammation was observed. Follow-up visits occurred weekly for 2 months or until clearance of all lesions, and then, 1 month later to check for recurrences. At each visit, the number of lesions, local reactions and systemic effects were recorded. If new lesions developed during the study, these were also treated and included in the data. In total, 35 patients aged 18–49 years (mean 29Æ3) were included. Genital warts were present on the glans, foreskin, scrotal area and penile shaft (Fig. 1a). The number of lesions ranged from one to 15 (mean 5Æ2) and size ranged from 0Æ3 to 2 cm (mean 1Æ1). All patients experienced mild inflammation (erythema and oedema) and reduction in the number of warts during the first week of treatment. Superficial erosions were present in 56%, stinging in 22% and hypopigmentation in 9% of treated patients. The period of treatment until patients were wart-free ranged from 1 to 8 weeks (mean 3Æ3). Thirty-two patients (91%) completed the study. Two patients did not return after the first visit. One patient developed a urethral lesion during the third week of treatment and was excluded from the trial. One patient had persistent lesions after 2 months of treatment, and threepatients presentednew lesions at the1-month follow-up visit. All four of these patients were considered treatment failures (12Æ5%). At the end of the trial, 87Æ5% of treated patients were completely wart free with no recurrences (Fig. 1b). Alkaline substances are strongly basic, yielding hydroxide ions (OH) in solution. KOH is a strong alkali widely used to visualize fungi in microscopic preparations of skin, hair and nail scrapings. KOH is mainly a mild irritant, i.e. one that does not cause a severe skin reaction due to brief contact. The present study was designed to evaluate the efficacy and safety of self-applied KOH topical solution in the treatment of genital warts. Two previous studies demonstrated the efficacy and safety of KOH in the treatment of molluscum contagiosum in children. In the first study, a home, parent-applied topical 10% aqueous KOH solution applied twice daily showed promising results with clearance of lesions in 91% of patients, although severe stinging and burning was reported. A second study, using 5% KOH solution, proved to be as effective as the 10% solution, but with fewer local side-effects. (a)

Perfil epidemiológico de mulheres com vaginose bacteriana, atendidas em um ambulatório de doenças sexualmente transmissíveis, em São Paulo, SP

BACKGROUND- Bacterial vaginosis is an important disease on account of its high prevalence as well as the obstetrical and gynecological complications. OBJECTIVE- To present an epidemiological profile of patients diagnosed with bacterial vaginosis seen at an outpatient clinic in the city of Sao Paulo, Brazil, described according to socio-demographic and clinical variables. METHODS- A cross-sectional descriptive study was performed by collecting data from the medical records of 658 females, seen from January, 1999 to December, 2004. Our study took into account age, ethnicity, marital status, schooling, sexual preference, number of partners and associated sexual diseases. RESULTS- The prevalence observed was 29%. Regarding the profile of women with bacterial vaginosis, the highest ratio of cases occurred in adolescents aged 10 to 19 years old (40%), black women (37.1%), widows (62.5%), women who have not graduated from high school (39.5%), heterosexual women (29.5%), women with two or more sexual partners in the last 30 days (50%) and in the last five years (35.3%). The concomitant association with other sexually transmitted diseases was found in 35% of cases. CONCLUSION- The distribution of bacterial vaginosis in patients according to age, ethnicity, number of sexual partners and associated sexual diseases was similar to that described in the literature. The observed ratio was within values of other studies (10 to 36%).

Itraconazol no tratamento da pitiríase versicolor: comparação entre 5 e 7 dias de tratamento

Os autores analisam os resultados obtidos no tratamento da pitiriase versicolor com o Itraconazol em estudo aberto, comparativo, na dose de 200 mg/dia por 5 e 7 dias. A diagnose foi estabelecida pelo exame clinico, fluorescencia pela luz de Wood exame micologico direto, sendo os pacientes reavaliados no 21o e 35o dia apos o inicio da terapeutica. Ambos os esquemas de tratamento utilizados mostraram-se eficazes. Os indices de cura clinica e micologica, obtidos no ultimo controle, foram de 90% para o grupo tratado por 5 dias e 95% para o grupo tratado por 7 dias. A tolerância a droga foi boa, tendo sido registrados efeitos colaterais em dois pacientes do grupo tratado por 7 dias e em um paciente do grupo tratado por 5 dias. Como nao houve diferenca estatisticamente significante entre ps grupos tratados, os autores recomendam o esquema de tratamento mais curto, ou seja, 200 mg/dia por 5 dias.

Immunopathological characterization of human cutaneous leishmaniasis lesions caused by Leishmania (Viannia) spp. in Amazonian Brazil

American cutaneous leishmaniasis (ACL) is a chronic infectious disease caused by different protozoan species of Leishmania, and it is endemic in both tropical and subtropical countries. Using immunohistochemistry, we investigate the density of CD68+, lysozyme+, CD1a+, factor XIIIa+, CD4+, CD8+, CD56+, interferon (IFN)-γ+, and inducible NO synthase (iNOS+) cells. These cells were analyzed from 22 biopsy samples obtained from the lesions of ACL patients, whose infection was caused by Leishmania (Viannia) spp. Histopathological analysis showed dense mononuclear inflammatory infiltration in the dermis, which was composed of lymphocytes, macrophages, plasma cells, and discrete tissue parasitism. Granulomatous reactions were also present in the majority of cases. The density of the activated macrophages was higher than that of inactivated macrophages in the lesions. The density of Langerhans cells (CD1a+) was lower than that of dermal dendrocytes (factor XIIIa+). The density of CD8+ T lymphocytes was higher than that of CD4+ T lymphocytes. The cellular density of these immunological markers in relation to the species of Leishmania demonstrated that L. (Viannia) sp. lesions had higher IFN-γ expression than that Leishmania (Viania) braziliensis lesions. The evaluation of these markers, according to disease progression, did not reveal any significant differences. L. (Viannia) sp. infection leads to a favorable immune response in the host, as predominantly represented by lysozyme+, factor XIIIa+, CD8+ T cells, and the expression of (IFN)-γ+ at the lesion site.

Anti-leishmania igA immunoenzymatic assay in mucocutaneous leishmaniasis (Preliminary report)

Os Autores descrevem a reacao de IgA ELISA na leishmaniose mucocutânea. Titulos acima do normal foram encontrados no primeiro e segundo anos de infeccao e em soros de micoses profundas acompanhados por envolvimento mucoso ou doenca disseminada.