Diagnosis of elephantiasis nostras verrucosa as a clinical mani-festation of Kaposi's sarcoma / Diagnóstico de elefantiasis nostras verrucosa como mani-festación clínica del Sarcoma de Kaposi

Elephantiasis nostras verrucosa, a rare manifestation of Kaposi's sarcoma, is a progressive cutaneous hypertrophy caused by chronic non-filarial lymphedema secondary to obstruction of the lymphatic system that can lead to severe disfigurement of parts of the body that have gravity-dependent blood flow, due to edema, fibrosis, and hyperkeratosis, especially lower extremities. Among the various conditions that can induce chronic lymphedema are tumors, trauma, radiotherapy, obesity, hypothyroidism, chronic venous stasis, and AIDS-related Kaposi's sarcoma. Kaposi's sarcoma is a vascular tumor associated with the presence of human gammaherpesvirus 8 that is predominantly cutaneous, locally aggressive, with metastasis, and is associated with the production of factors that favor inflammation, lymphatic obstruction, and lymphedema.

Thalidomide in plasma cell balanitis refractory to conventional topical treatment

Abstract: Zoon's plasma cell balanitis is a chronic genital inflammatory dermatosis that affects uncircumcised men, especially the elderly. It's characterized by painless erythematous plaques of orange hue, located on the glans penis and foreskin. Circumcision is the most effective treatment; however, it can be hard for patients to accept. As an alternative, topical calcineurin inhibitors are used, with good response. This article reports the case of a 32-year-old patient, HIV carrier, diagnosed with Zoon's plasma cell balanitis. Treatment with topical tacrolimus was administered, without improvement. A 6-week course of thalidomide resulted in complete remission of the lesions, without recurrence after eight months of follow-up.

Kaposi's sarcoma in persons living with HIV/AIDS: a case series in a tertiary referral hospital

Abstract: Background: Kaposi's sarcoma (KS) is a rare neoplasm with indolent progression. Since 1981, the Kaposi's sarcoma epidemic has increased as co-infection with HIV. Objectives: The study aimed to identify the clinical and demographic characteristics and therapeutic approaches in HIV/AIDS patients in a regional referral hospital. Methods: We analyzed the medical records of 51 patients with histopathological diagnosis of Kaposi's sarcoma hospitalized at Hospital Universitário João de Barros Barreto (HUJBB) from 2004 to 2015. Results: The study sample consisted of individuals 15 to 44 years of age (80.4%), male (80.4%), single (86.3%), and residing in Greater Metropolitan Belém, Pará State, Brazil. The primary skin lesions identified at diagnosis were violaceous macules (45%) and violaceous papules (25%). Visceral involvement was seen in 62.7%, mainly affecting the stomach (75%). The most frequent treatment regimen was 2 NRTI + NNRTI, and 60.8% were referred to chemotherapy. Study limitations: We assumed that more patients had been admitted to hospital without histopathological confirmation or with pathology reports from other services, so that the current study probably underestimated the number of KS cases. Conclusion: Although the cutaneous manifestations in most of these patients were non-exuberant skin lesions like macules and papules, many already showed visceral involvement. Meticulous screening of these patients is thus mandatory, even if the skin lesions are subtle and localized.

The diagnosis of multiple opportunistic infections in advanced stage AIDS: when Ockham's Razor doesn't cut it

In the advanced stage of AIDS, the diagnosis of the opportunistic infections may be challenging due to the high risk of performing invasive diagnostic methods in a patient with a critical clinical condition, as well as the correct interpretation of the results of microbiological exams. One of the challenges for the diagnosis and treatment of the opportunistic infections is that they may occur concomitantly in the same patient and they may mimic each other, leading to a high discrepancy between clinical and autopsy diagnoses. We describe the case of a 52-year-old man who was hospitalized because of weight loss, anemia, cough, and hepatosplenomegaly. During the investigation, the diagnosis of AIDS was made, and the patient developed respiratory failure and died on the fourth day of hospitalization. At autopsy, disseminated non-tuberculosis mycobacteriosis was found, affecting mainly the organs of the reticuloendothelial system. Also, severe and diffuse pneumonia caused by multiple agents (Pneumocystis jirovecii, Histoplasma capsulatum, suppurative bacterial infection, non-tuberculosis mycobacteria, and cytomegalovirus) was seen in a morphological pattern that could be called "collision pneumonia." The lesson from this case, revealed by the autopsy, is that in advanced AIDS, patients often have multiple opportunistic infections, so the principle of Ockham's razor­that a single diagnosis is most likely the best diagnosis­fails in this clinical context.

Morphological changes in the digestive system of 322 necropsies of patients with acquired immune deficiency syndrome: comparison of findings pre- and post-HAART (Highly Active Antiretroviral Therapy)

ABSTRACT Involvement of the digestive system in AIDS pathologies or injuries is frequent. Aiming at comparing the frequency, the importance that these lesions have for death and the survival time in patients using or not using HAART, we studied 322 necropsies classified as follows: Group A - without antiretroviral drugs (185 cases); B - one or two antiretroviral drugs or HAART for less than six months (83 cases); C - HAART for six months or longer (54 cases). In the overall analysis of the digestive system, changes were present in 73.6% of cases. The most frequent was Candida infection (22.7%), followed by cytomegalovirus (19.2%), Histoplasma capsulatum (6.5%), mycobacteria (5.6%), and Toxoplasma gondii (4.3%). T. gondii infection was more frequent in group A compared with group C, and cytomegalovirus (CMV) was more frequent in group A compared with groups B and C (p < 0.05); 2.2% of the deaths were due to gastrointestinal bleeding. Regarding the segments, only in the large intestine, and only cytomegalovirus, were more frequent in group A compared with group C. We conclude that digestive system infections are still frequent, even with the use of HAART. However, the average survival time in group C was more than three times greater than the one in group A and nearly double that of group B, demonstrating the clear benefit of this therapy.

Angiosarcoma in HIV-negative patients is not associated with HHV-8

Abstract: BACKGROUND: Angiosarcoma is an aggressive, malignant neoplasm of vascular or lymphatic origin. Herpes virus 8 (HHV-8) is a member of the herpes family with a tropism for endothelial cells and it has been proven to induce vascular neoplasms, such as Kaposi's sarcoma. The role of HHV-8 in the pathogenesis of angiosarcoma has not been well defined. OBJECTIVE: To investigate the relationship between the presence of HHV-8 and angiosarcoma. METHODS: In this study, the team investigated the relationship between the presence of HHV-8, as determined by polymerase chain reaction, and angiosarcoma, using samples from patients with epidemic Kaposi's sarcoma as controls. RESULTS: While all control cases with epidemic Kaposi's sarcoma were positive for HHV-8, none of the angiosarcoma cases was. CONCLUSION: These findings support most previous studies that found no association between HHV-8 and angiosarcoma.

Bacillary angiomatosis with bone invasion

Abstract Bacillary angiomatosis is an infection determined by Bartonella henselae and B. quintana, rare and prevalent in patients with acquired immunodeficiency syndrome. We describe a case of a patient with AIDS and TCD4+ cells equal to 9/mm3, showing reddish-violet papular and nodular lesions, disseminated over the skin, most on the back of the right hand and third finger, with osteolysis of the distal phalanx observed by radiography. The findings of vascular proliferation with presence of bacilli, on the histopathological examination of the skin and bone lesions, led to the diagnosis of bacillary angiomatosis. Corroborating the literature, in the present case the infection affected a young man (29 years old) with advanced immunosuppression and clinical and histological lesions compatible with the diagnosis.

Histoplasmosis diseminada en pacientes HIV/SIDA: Buenos Aires, 2009-2014 / Disseminated histoplasmosis in patients with AIDS. Buenos Aires, 2009-2014

Durante 2009-2014, en nuestro hospital fueron diagnosticados 171 casos de histoplasmosis en pacientes con HIV/sida: 64 en 2009-2011, y 107 en 2012-2014. El mayor número de casos durante el segundo trienio no tuvo relación con la infección por HIV, cuya tasa de diagnóstico permaneció estable. La relación hombre/mujer fue 3.7:1 y la edad media 37.4 años. Al diagnóstico, solo 54/171 (31.6%) recibían TARGA y el recuento de linfocitos T CD4+ varió entre 4 y 264 células/μl. El 64.3% (n = 110) presentó lesiones cutáneas (pápulas ulceradas o "moluscoides") positivas para Histoplasma capsulatum al examen microscópico con tinción Giemsa. Siguieron en frecuencia las manifestaciones respiratorias y el lavado broncoalveolar fue positivo en 41/171 (24.0%) pacientes. Las imágenes radiológicas más frecuentes en orden decreciente fueron patrón miliar, infiltrados intersticiales y condensaciones focales. Se aisló H. capsulatum en 82 (58.2%) de los 141 hemocultivos realizados. No hubo diferencia significativa entre el rendimiento diagnóstico del hemocultivo y el de las escarificaciones cutáneas (p = 0.6164). Otras infecciones oportunistas previas o concomitantes con la histoplasmosis se observaron en 70/171 (40.9%). Se registró asociación con tuberculosis en 16/171 (9.4%) y un aislamiento de Mycobacterium tuberculosis resultó multirresistente. La gravedad del caso determinó el tratamiento con anfotericina B desoxicolato en 115 (67.3%), con itraconazol en 43 (25.1%), y con terapias combinadas en 14 (8.2%). La letalidad fue 19.9% (34/171). La mayor prevalencia en el segundo trienio debe alertar a la comunidad médica a considerar el diagnóstico de la histoplasmosis en pacientes con HIV/sida para disminuir la mortalidad.

A retrospective study was carried out on 171 cases of disseminated histoplasmosis diagnosed in HIV/AIDS patients during the period 2009-2014. Although HIV diagnosis rates remained stable over the study period, a sensible increase in the number of histoplasmosis cases was observed in the last three years. Disseminated histoplasmosis was prevalent in males with an average age of 37.8 years. At diagnosis, only 54/171 (31.6%) were receiving HAART, and CD4+ T-lymphocyte counts ranged from 4 to 264 cells/μl. Cutaneous lesions, including ulcerated papules or molluscoid plaques, were present in 110/171 (64.3%), with Histoplasma capsulatum being observed in all skin scraping specimens upon Giemsa staining. Respiratory manifestations were second in frequency with bronchoalveolar lavage showing a high diagnostic performance. Radiological findings included milliary patterns, interstitial infiltrates, and focalized condensations. Out of 141 blood cultures performed, H. capsulatum was isolated in 82 (58.2%). No significant difference in diagnostic performance was found between blood cultures and skin scraping (p = 0.6164). Other opportunistic infections were observed in 70/171 (40.9%) prior to or concomitantly with histoplasmosis. Association with Mycobacterium tuberculosis was recorded in 16/171 (9.4%) and one had a multi-drug resistant isolate. The severity of histoplasmosis determined the monotherapy with amphotericin B deoxycholate in 115 (67.3%), itraconazole in 42 (24.5%), and combined therapies in 14 (8.2%). Mortality was 19.9% (34/171). Finally, we emphasize that the higher prevalence in the last three years of the study should prompt the medical community to consider the diagnosis of histoplasmosis to reduce mortality of AIDS patients.

Lesiones orales asociadas con la enfermedad del virus de inmunodeficiencia humana en pacientes adultos, una perspectiva clínica / Oral lesions associated with human immunodeficiency virus disease in adult patients, a clinical perspective

Among the clinical manifestations which may occur in HIV/AIDS patients, oral lesions are relevant because there are easily accessible and usually the diagnosis is made through clinical features. Some oral manifestations are strongly related with HIV/AIDS patients indicating infection and progression to AIDS and also allow monitoring the success or failure of using antiretroviral therapy. The massive introduction of antiretroviral therapy has changed the morbidity and mortality, frequency, type of clinical manifestation and the timing of the classic opportunistic complications. The aim of this review is to provide an updated of the classical clinical features of the most frequent and relevant HIV/AIDS oral manifestations, considering the fundamental clinical features for their diagnosis.

Dentro de las manifestaciones que pueden aparecer en los pacientes con infección por VIH/SIDA, las lesiones de la cavidad oral tienen gran relevancia debido a que son fácilmente accesibles y por lo general su diagnóstico se efectúa a través de signos clínicos. Además, algunas manifestaciones orales están fuertemente relacionadas con el síndrome por lo que indican sospecha de infección y progresión a etapa SIDA y permiten monitorizar el éxito o fracaso de la terapia anti-retroviral empleada. La introducción masiva de la terapia anti-retroviral ha modificado la morbi-mortalidad, la frecuencia, el tipo de manifestación clínica y el momento de aparición de las clásicas complicaciones oportunistas. El objetivo de esta revisión es entregar las características clínicas clásicas actualizadas de aquellas manifestaciones orales asociadas a la infección por VIH/SIDA que son más frecuentes y que tienen mayor relevancia clínica, considerando las características fundamentales para su diagnóstico.

Human herpesvirus 8 (HHV-8) detected by nested polymerase chain reaction (PCR) in HIV patients with or without Kaposi's sarcoma. An analytic cross-sectional study / Herpesvírus humano 8 (HHV-8) detectado por reação da polimerase em cadeia do tipo nested PCR em pacientes HIV-positivos com ou sem sarcoma de Kaposi. Um estudo transversal analítico

CONTEXT AND OBJECTIVE: Kaposi's sarcoma (KS) is a common neoplastic disease in AIDS patients. The aim of this study was to evaluate the frequency of human herpesvirus 8 (HHV-8) infection in human immunodeficiency virus (HIV)-infected patients, with or without KS manifestations and correlate HHV-8 detection with KS staging. DESIGN AND SETTING: Analytic cross-sectional study conducted in a public tertiary-level university hospital in Ribeirão Preto, São Paulo, Brazil. METHODS: Antibodies against HHV-8 lytic-phase antigens were detected by means of the immunofluorescence assay. HHV-8 DNA was detected in the patient samples through a nested polymerase chain reaction (nested PCR) that amplified a region of open reading frame (ORF)-26 of HHV-8. RESULTS: Anti-HHV-8 antibodies were detected in 30% of non-KS patients and 100% of patients with KS. Furthermore, the HHV-8 DNA detection rates observed in HIV-positive patients with KS were 42.8% in serum, 95.4% in blood samples and 100% in skin biopsies; and in patients without KS, the detection rate was 4% in serum. Out of the 16 serum samples from patients with KS-AIDS who were classified as stage II, two were positive (12.5%); and out of the 33 samples from patients in stage IV, 19 (57.6%) were positive. CONCLUSION: We observed an association between HHV-8 detection and disease staging, which was higher in the serum of patients in stage IV. This suggests that detection of HHV-8 DNA in serum could be very useful for clinical assessment of patients with KS and for monitoring disease progression.

CONTEXTO E OBJETIVO: Sarcoma de Kaposi (SK) é uma doença neoplásica comum em pacientes com aids. O objetivo deste estudo foi avaliar a frequência da infecção por herpesvírus humano 8 (HHV-8) em pacientes infectados por HIV, com ou sem SK e associar a detecção do HHV-8 com o estadiamento do SK. TIPO DE ESTUDO E LOCAL: Estudo transversal analítico realizado em hospital universitário público terciário de Ribeirão Preto, São Paulo, Brasil. MÉTODOS: Anticorpos contra antígenos de fase lítica do HHV-8 foram detectados por imunofluorescência. O DNA viral de HHV-8 foi detectado em amostras de pacientes pela reação em cadeia da polimerase do tipo nested (nested PCR), que amplificou uma região do fragmento de leitura aberta (ORF)-26 do HHV-8. RESULTADOS: Anticorpos anti-HHV-8 foram detectados em 30% dos pacientes sem SK e 100% dos com SK. Além disso, a detecção de HHV-8 DNA observada em pacientes HIV-positivos com SK foi de 42,8% no soro, 95,4% em amostras de sangue e 100% em biópsias de pele, e em pacientes sem SK foi de 4% no soro. Das 16 amostras de soro de pacientes com SK-AIDS classificados como estádio II, duas foram positivas (12,5%) e, das 33 amostras de pacientes no estádio IV, 19 (57,6%) foram positivas. CONCLUSÃO: Observamos associação entre a detecção do HHV-8 e o estadiamento da doença, que foi maior no soro de pacientes no estágio IV. Isso sugere que a detecção do HHV-8 no soro poderia ser muito útil para a avaliação clínica de pacientes com SK e para o monitoramento da progressão da doença.

Fatal disseminaeed cryptococcosis with renal involvement in an HIV-infected patient / Criptococose disseminada fatal com envolvimento renal em paciente infectado pelo HIV

SUMMARYIntroduction: We present a fatal case of disseminated cryptococcosis in a young man whose diagnosis of HIV infection was made at the time of admission to the emergency room.Case report: The patient was a twenty-three-year-old man, with a history of daily fever during one month associated with diarrhea, weight loss, headache, vomiting and generalized seizures. He also had a history of diabetes mellitus, alcoholism and drug addiction. Upon physical examination the patient was pale, disoriented and had periods of agitation. White blood cells count was 3,440/mm3 (5% lymphocytes), hemoglobin was 10g/dL, platelets were 83,000/ mm3. Creatinine was 0.7 mg/dL; urea 19 mg/dL; Na, K, and liver enzymes were within normal limits. Lactic dehydrogenase was 494 IU/L. Cerebrospinal fluid (CSF) analysis revealed 10 white blood cells/mm3 (58% neutrophils, 31% lymphocytes, 11% monocytes) and 2 red blood cells/mm3. India ink test revealed six Cryptococcusyeasts/mm3. CSF glucose was 122 mg/dL and protein was 36 mg/ dL. VDRL test was negative and anti-HIV test was positive. Intravenous hydration, insulin, phenytoin, fluconazole, pyrimethamine, sulfadiazine, folinic acid, and amphotericin B were started. The patient did not improve and became obtunded and hypotensive. He was intubated and put on mechanical respiration. He received vasoactive drugs and died less than 24 hours after admission. A postmortem examination was performed and revealed disseminated cryptococcosis, with severe involvement of the kidneys.Conclusion:Cryptococcosis, as a rule, is a systemic disease that affects mostly immunocompromised individuals, especially patients with AIDS. When diagnosed late in its course it has a very high mortality.

RESUMOIntrodução: Apresentamos um caso fatal de criptococose disseminada em homem jovem cujo diagnóstico de HIV foi feito no momento da admissão na emergência.Relato de caso: O paciente, de 23 anos, sexo masculino, tinha história de febre diária de um mês de duração, associada à diarreia, perda de peso, cefaleia, vômitos e convulsões generalizadas. Tinha ainda história de diabetes mellitus, alcoolismo e drogadição. Ao exame físico havia palidez, desorientação e períodos de agitação. Os exames laboratoriais mostraram 3.440 leucócitos/mm3(5% linfócitos), hemoglobina de 10 g/dL, 83,000 plaquetas/mm3, creatinina de 0,7mg/dL, ureia de 19 mg/dL, Na, K e enzimas hepáticas dentro dos limites da normalidade. A lactato desidrogenase era 494 UI/L. Análise do líquor revelou 10 leucócitos/mm3 (58% neutrófilos, 31% linfócitos, 11% monócitos) e 2 hemácias/mm3, glicose de 122 mg/dL e proteína de 36 mg/dL. A análise com tinta da Índia revelou seis blastoconídeos de Cryptococcus/mm³. O VDRL foi negativo e o anti-HIV positivo. Foi iniciado tratamento com hidratação venosa, insulina, fenitoína, fluconazol, pirimetamina, sulfadiazina, ácido folínico e anfotericina B. O paciente não apresentou melhora e evoluiu com obnubilação e hipotensão, sendo intubado e iniciada ventilação mecânica. Foram administradas drogas vasoativas, e o paciente evoluiu a óbito menos de 24h após a admissão. A autópsia revelou criptococose disseminada, com grave envolvimento renal.Conclusão:A criptococose é via-de-regra, doença sistêmica que afeta principalmente indivíduos imunocomprometidos, especialmente com AIDS, e quando diagnosticada tardiamente apresenta alta mortalidade.

Atypical presentation of histoplasmosis in an immunocompromised patient

We present a case of disseminated cutaneous histoplasmosis in a male patient, rural worker, HIV positive for 20 years, with a history of irregular use of antiretroviral therapy, T cell counts below 50 cells/mm3 and with good response to treatment with Itraconazole. We highlight importance of skin lesions in clarifying early diagnosis, since this co-infection often leads patients to death.

Neumonitis por citomegalovirus en pacientes con sida fallecidos / Pneumonitis caused by cytomegalovirus in dead aids patients

Introducción: El citomegalovirus (CMV) es considerado un germen oportunista común entre individuos con infección por el virus de inmunodeficiencia humana (VIH) y con frecuencia produce enfermedades en diferentes órganos. Objetivo: Conocer la incidencia de esta entidad en nuestro medio. Material y método: Se realizó un estudio descriptivo ambispectivo que incluyó 105 de las 674 autopsias realizadas en pacientes con sida fallecidos en el Instituto de Medicina Tropical Pedro Kourí, con el diagnóstico postmorten de enfermedad por CMV en el período comprendido entre 1986 y 2008. Se describe el comportamiento de variables sociodemográficas, principales órganos afectados, correlación clínico-patológica, hallazgos clínicos y de laboratorio, relación entre el conteo de linfocitos T CD4+ y las formas clínicas de la enfermedad. Resultados: Predominó el sexo masculino en una proporción 4:1 y el color de piel blanco (80,2 por ciento). El 66,6 por ciento de los casos tenía enfermedad diseminada. Las glándulas suprarrenales (41,9 por ciento), el tubo digestivo (30,5 por ciento) y el encéfalo (17,1por ciento) fueron los órganos más afectados. La fiebre (51,4 por ciento), la diarrea (42,9 por ciento), las convulsiones (31,4 por ciento) y el desgaste físico (17,1 por ciento) fueron los síntomas más frecuentes. Los niveles de lactato deshidrogenasa (LDH) mayores de 600 mmol/L se asociaron fuertemente a CMV como causa de muerte (p= 0,005). Aproximadamente el 70 por ciento de los pacientes tenía menos de 100 células/µL y el 37,5 por ciento menos de 50 células/µL, aunque esto no influyó de manera significativa en las formas clínicas de presentación (p0,641). Conclusiones: La enfermedad por CMV se diagnosticó mayormente postmorten, diseminada y asociada con niveles elevados de LDH y conteo de linfocitos T CD4 menor de 100 células/µL...

Introduction : Cytomegalovirus (CMV) is considered a common opportunistic germ in individuals infected with human immunodeficiency virus (HIV) often causing disease in different organs. Objective: To determine the incidence of this condition in our environment. Material and Methods: A descriptive, ambispective study that included 105 of the 674 autopsies of AIDS patients died at the Institute of Tropical Medicine Pedro Kouri, with postmortem diagnosis of CMV disease, between 1986 and 2008. Sociodemographic variables, main organs affected, clinical and pathological correlation, clinical and laboratory findings, relation between CD4 + T cells count and clinical forms of the disease are described. Results: Males predominated in a ratio 4:1 as well as white skin color (80.2 percent). 66.6 percent of patients had disseminated disease. Adrenal glands (41.9 percent), gastrointestinal tract (30.5 percent) and brain (17.1percent) were the most affected organs. Fever (51.4 percent), diarrhea (42.9 percent), seizures (31.4 percent) and physical consumption (17.1 percent) were the most frequent symptoms. LDH levels >600 mmol/L were strongly associated to CMV as cause of death (p = 0.005). Nearly 70 percent of patients had less than 100 cells/µL and 37.5 percent less than 50 cells/µL, although this had no significant influence in the clinical forms of presentation (p = 0.641). Conclusions: CMV disease was mainly diagnosed postmortem, usually spread and in association with high levels of LDH and CD4 count lesser than 100 cells/µL...

Update on cutaneous tuberculosis

Tuberculosis continues to draw special attention from health care professionals and society in general. Cutaneous tuberculosis is an infection caused by M. tuberculosis complex, M. bovis and bacillus Calmette-Guérin. Depending on individual immunity, environmental factors and the type of inoculum, it may present varied clinical and evolutionary aspects. Patients with HIV and those using immunobiological drugs are more prone to infection, which is a great concern in centers where the disease is considered endemic. This paper aims to review the current situation of cutaneous tuberculosis in light of this new scenario, highlighting the emergence of new and more specific methods of diagnosis, and the molecular and cellular mechanisms that regulate the parasite-host interaction.

Leishmaniasis mucocutánea en un paciente con infección por VIH: Case report / Mucocutaneous leishmaniasis in a HIV infected patient

Introduction: Leishmaniasis is an endemic Andean vector-borne- tropical disease in Peru, whose mucocutaneous clinical presentation is rare. Leishmaniasis can occur in co-infections with HTLV-1 virus and HIV. We describe a case of L. mucocutaneous in a patient infected with HIV, with a history of cutaneous leishmaniasis with inadequate treatment 20 years ago. He was treated with stibogluconate with adequate response to treatment and regression of lesion after 4 weeks. Mucocutaneous leishmaniasis and HIV coinfection is rare and its clinical presentation may be atypically. It is important to consider it in patients coming from endemic areas and with a history of a previous cutaneous clinical presentation.

La leishmaniasis es una enfermedad metaxénica andino-tropical, considerada endémica en Perú. Su forma mucocutánea es poco frecuente. Puede presentarse en coinfección con los virus HTLV-1 y VIH. Se describe un caso de leishmaniasis mucocutánea en un paciente infectado con VIH, con antecedente de leishmaniasis cutánea con tratamiento incompleto 20 años atrás. Es tratado con estibogluconato sódico por 30 días, con adecuada respuesta y regresión de la lesión a las cuatro semanas. La coinfección de leishmaniasis mucocutánea y VIH no es frecuente. Las manifestaciones de leishmaniasis pueden no presentarse de forma típica en pacientes con VIH. Se debe considerar la procedencia de la zona endémica y/o el antecedente de haber presentado la forma cutánea previamente.

Indeterminate leprosy and lepromatous index case: four cases in the same family / Hanseniase indeterminada e caso indice virchowiano: 4 casos na mesma familia

Leprosy is a chronic infectious disease caused by Mycobacterium leprae, which primarily affects the skin and peripheral nerves. Brazil remains as the country with the second largest number of cases in the world. We report the case of three patients diagnosed with indeterminate leprosy in the same family. Two patients were HIV positive. An active search led to the discovery of the index case. It was crucial to persist in the search of the index case. This report shows how important it is to teach physicians and the general population about the signs and symptoms of leprosy. Early diagnosis and treatment are necessary to prevent sequelae and to eliminate the disease as a public health problem.

A hanseníase é uma doença infecciosa crônica causada pelo Mycobacterium leprae, que afeta principalmente a pele e nervos periféricos. O Brasil continua sendo o segundo país do mundo com maior número de casos. Aqui relatamos três pacientes diagnosticados com hanseníase indeterminada, pertencentes à mesma família, cuja busca ativa levou à descoberta do caso índice. Dois pacientes eram HIV positivos. Foi de imensa importância a insistência na procura pelo caso índice. Este relato ilustra a importância do ensino sobre sinais e sintomas de hanseníase na formação médica e à população. O pronto reconhecimento e tratamento são necessários para prevenir sequelas e eliminar a doença como problema de saúde pública.

Herpes-zóster com manifestação bucal em paciente imunossuprimido: relato de caso / Herpes zoster with oral manifestation in na immunocompromised patient: a case report

O herpes-zóster é uma infecção viral causada pela reativação do vírus da varicela-zóster. Esta doença pode afetar pacientes imunossuprimidos e caracteriza-se por lesões papulovesiculares distribuídas na região inervada pelo nervo afetado, causando dores intensas. Este artigo relata o caso de um paciente do sexo masculino, leucoderma, 26 anos de idade, dependente químico, HIV positivo e com tuberculose ganglionar que procurou o Hospital Oswaldo Cruz (Curitiba/PR) tendo como queixa mal-estar geral, lesões na pele e mucosa oral, e linfadenopatia na região cervical. Discussão: O diagnóstico do herpes-zóster foi estabelecido por meio das características clínicas das lesões, e o tratamento estabelecido envolveu o uso de drogas antirretrovirais, analgésicos e antidepressivos. Conclusão: O cirurgião-dentista precisa estar atento às lesões papulovesiculares que acometem a pele e as mucosas de forma unilateral, acompanhadas de sintomas de prurido e dor, pois elas garantem o diagnóstico do herpes-zóster...

Herpes zoster is a viral infection caused by the reactivation of varicella zoster virus. This disease can affect immunocompromised patients and is characterized by papulovesicular lesions distributed in the inner¬vated region by the affected nerve and may result in severe pain. This article reports the case of a male patient, leucoderm, 26 years old, user of illicit drugs, HIV positive and with lymph node tuberculosis, who came to the hospital Oswaldo Cruz (Curitiba, Paraná, Brazil), having as general complaint malaise, skin and oral lesions, and cervical lymphadenopathy. Discussion: The diagnosis of herpes zoster has been established by clinical characteristics of the lesions and established treatment involved the use of antiretroviral drugs, analgesics and antidepressants. Conclusion: The dentist needs to be aware of papulovesicular lesions affecting the skin and mucous membranes unilaterally followed by symptoms of pruritus and pain, for these ensure the diagnosis of herpes zoster...

Immunohistochemical detection of the latent nuclear antigen-1 of the human herpesvirus type 8 to differentiate cutaneous epidemic Kaposi sarcoma and its histological simulators / Detecção imuno-histoquímica do antígeno nuclear latente-1 do herpesvirus tipo 8 para diferenciar o sarcoma de Kaposi epidêmico cutâneo de seus simuladores histológicos

Kaposi's sarcoma is the most common neoplasia diagnosed in AIDS patients and the expression of the human herpesvirus-8 (HHV-8) latent nuclear antigen-1 has been useful for its histological diagnosis. The aim of this study is to confirm that immunohistochemistry is a valuable tool for differentiating KS from its simulators in skin biopsies of HIV patients. Immunohistochemical and histological analyses were performed in 49 Kaposi's sarcoma skin biopsies and 60 of its histological simulators. Positivity was present in the 49 Kaposi's sarcoma skin biopsies and no staining was observed in the 60 simulators analyzed, resulting in sensibility and specificity of 100%. HHV-8 immunohistochemical detection is an effective tool for diagnosing Kaposi's sarcoma, especially in early lesions in which neoplastic features are not evident. It also contributes to its histological differential diagnosis.

O sarcoma de Kaposi é a neoplasia mais diagnosticada em pacientes com SIDA e a expressão do antígeno nuclear latente-1 do herpesvírus humano tipo-8 (HHV-8) tem se mostrado útil no seu diagnóstico histológico. O objetivo deste estudo é confirmar que o método imuno-histoquímico é uma ferramenta útil para diferenciar o sarcoma de Kaposi cutâneo de seus simuladores histológicos em pacientes HIV positivos. Análise histológica e imuno-histoquímica foram realizadas em 49 casos de sarcoma de Kaposi cutâneo e 60 casos de seus simuladores histológicos. Positividade à imuno-histoquímica para o antígeno nuclear latente 1 do HHV-8 foi observada nos 49 casos de sarcoma de Kaposi e nenhuma reação foi detectada nos 60 simuladores analisados, resultando em 100% de sensibilidade e especificidade. A detecção do HHV-8 por imuno-histoquímica é uma ferramenta útil para o diagnóstico de sarcoma de Kaposi, especialmente na lesão inicial cujo caráter neoplásico não é evidente, e contribui para seu diagnóstico diferencial histológico.

Lymphangiectatic Kaposi's sarcoma in a patient with AIDS / Sarcoma de Kaposi linfangiectásico em paciente com Aids

Kaposi's sarcoma is a malignant disease that originates in the lymphatic endothelium. It has a broad spectrum of clinical manifestations. Its four distinct clinical forms are: classic, endemic, iatrogenic and epidemic Kaposi's sarcoma. In non-HIV-associated Kaposi's sarcoma, the disease is typically limited to the lower extremities, but in immunodeficient patients, it is a multifocal systemic disease. The clinical course of the disease differs among patients, ranging from a single or a few indolent lesions to an aggressive diffuse disease. Advanced Kaposi's sarcoma lesions, typically those on the lower extremities, are often associated with lymphedema. In this paper, we report a case of a patient with a rare form of AIDS-associated Kaposi sarcoma called lymphangiectatic Kaposis's sarcoma. .

O sarcoma de Kaposi é uma neoplasia originária do endotélio linfatico, que apresenta um amplo espectro de manifestações, com quatro formas clínicas: sarcoma de Kaposi clássico, endêmico, iatrogêncio e epidêmico ou associado ao HIV. Em pacientes imunocompetentes, a doença é tipicamente limitada às extremidades. Porém em pacientes imunideprimidos, o sarcoma de Kaposi é uma doença sistêmica multifocal. Apresenta cursos clínicos diferentes, desde simples lesões cutâneas isoladas até lesões agressivas e difusas, com ou sem envolvimento sistêmico. Lesões avançadas de sarcoma de Kaposi, principalmente as localizadas nas extremidades, podem apresentar linfedema. Neste trabalho, reportamos caso de paciente com forma rara de Sarcoma de Kaposi associado a Aids, chamada de sarcoma de Kaposi linfangiectásico. .