Comportamiento clínico-epidemiológico del eritema nudoso en el Hospital Provincial Docente Clínico Quirúrgico León Cuervo Rubio / Epidemiological clinical behavior of erythema nodosum at the Provincial Teaching Clinical Surgical Hospital Leon Cuervo Rubio

RESUMEN Introducción: el eritema nudoso es la variante clínico-patológica más frecuente de la paniculitis. Es una reacción cutánea inmunológica en respuesta a un amplio espectro de agentes etiológicos. Objetivo: caracterizar el comportamiento clínico-epidemiológico del eritema nudoso. Materiales y métodos: se realizó un estudio descriptivo, prospectivo y longitudinal en pacientes con diagnóstico de eritema nudoso, ingresados en el Hospital Provincial Docente Clínico Quirúrgico León Cuervo Rubio, de Pinar del Río, en el período de enero de 2017 a diciembre de 2018. El universo estuvo constituido por 34 pacientes con diagnóstico clínico de eritema nudoso, hospitalizados en los servicios de Medicina Interna y Dermatología. Para la recogida de la información se utilizaron la historia clínica, el examen físico y los exámenes de laboratorio. Se utilizaron métodos teóricos, empíricos y estadísticos; de los últimos se empleó la estadística descriptiva a través de frecuencias absolutas y porcentaje. Resultados: el mayor grupo de pacientes estuvo entre 30 y 39 años, y fue del sexo femenino. Las lesiones fueron más frecuentes en los meses de invierno. El tipo de eritema nudoso idiopático prevaleció. Predominó el tiempo de evolución de 1 a 3 meses. Como causa secundaria predominaron las infecciones, y los tratamientos más usado fueron los antiinflamatorios no esteroideos. Conclusiones: se trata de una importante enfermedad de salud, cuyo un diagnóstico etiológico temprano permite un tratamiento adecuado. Resulta difícil su identificación y manejo tanto en la atención primaria como en la secundaria (AU).

ABSTRACT Introduction: erythema nodosum is the most common clinical-pathological variant of panniculitis. It is an immunological skin reaction in response to a wide spectrum of etiologic agents. Objective: to characterize the clinical-epidemiological behavior of erythema nodosum. Materials and methods: a descriptive, prospective and longitudinal study was carried out in patients with diagnosis of erythema nodosum, admitted to the Provincial Teaching Clinical Surgical Hospital León Cuervo Rubio, of Pinar del Río, in the period January 2017 to December 2018. The universe was formed by 34 patients with clinical diagnosis of erythema nodosum, hospitalized in the services of Internal Medicine and Dermatology. Medical records, physical examination and laboratory tests were used for the collection of information. Theoretical, empirical and statistical methods were used; descriptive statistics was used through absolute frequencies and percentage. Results: the largest group of patients was between 30 and 39 years, and they were female. Injuries were more frequent in the winter months. The type of idiopathic erythema nodosum prevailed. The time of evolution prevailed from 1 to 3 months. Infections predominated as a secondary cause, and the most commonly used treatments were non-steroidal anti-inflammatory drugs. Conclusions: it is an important health condition, whose early etiological diagnosis allows the proper treatment. Its identification and management in both primary and secondary care is difficult (AU).

Lepra lepromatosa nodular de diagnóstico tardío procedente de la Amazonía peruana, con el desarrollo de una reacción tipo 2 / Late diagnosis nodular lepromatous leprosy from the Peruvian Amazon, with development of a type 2 reaction

Resumen La lepra o enfermedad de Hansen es una de las clásicas enfermedades olvidadas que aún persiste en Perú. La infección es ocasionada por Mycobacterium leprae. La enfermedad varía en un amplio rango de manifestaciones desde la lepra tuberculoide (paucibacilar) hasta la lepromatosa (multibacilar). Se presenta el caso de un varón de 55 años, agricultor y extractor de madera, procedente de la Amazonia peruana, con lesiones cutáneas antiguas infiltrantes en la cara, cuello, tórax, abdomen y extremidades. La baciloscopia y estudio histológico de una biopsia de piel confirmaron la presencia de bacilos ácido-alcohol resistentes. Se concluyó, en forma tardía, que fue un caso de lepra lepromatosa nodular. Recibió terapia con rifampicina, dapsona y clofamizina por dos años con una lenta mejoría; no obstante, cursó con un eritema nodoso leproso (reacción tipo 2) con buena respuesta a corticoesteroides y talidomida.

Abstract Leprosy or Hansen's disease is one of the classic neglected diseases that still persists in Peru. The infection is caused by Mycobacterium leprae. The disease varies in a wide range of manifestations from tuberculoid (paucibacillary) to lepromatous (multibacillary) leprosy. We present the case of a 55-year-old man, farmer and wood extractor, from the Peruvian Amazon with old infiltrating cutaneous lesions on the face, neck, thorax, abdomen and extremities. The smear and biopsy examinations confirm the presence of acid-alcohol-resistant bacilli compatible with leprosy. It is concluded, with a long delay, it was a case of nodular lepromatous leprosy. He received therapy with rifampicin, dapsone and clofamizine for two years with slow progressive improvement; however, he presented an erythema nodosum leprosum (type 2 reaction) with response to corticosteroids and thalidomide.

Leucemia mieloide aguda y policondritis recurrente ¿casualidad o relación causal? / Acute myeloid leukemya and relapsing polychondritis. Chance or causal relationship?

La policondritis recurrente o recidivante es una enfermedad sistémica crónica autoinmune, caracterizada por la inflamación de tejidos cartilaginosos asociada en pocos casos a enfermedades malignas hematológicas. Presentamos el caso de una paciente femenina de 26 años que cursaba concomitantemente con leucemia mieloide aguda (LMA). La manifestación inicial fue una afección cutánea en forma de eritema nodoso, y posteriormente se diagnosticó LMA; durante la fase de aplasia posquimioterapia desarrolló inflamación bilateral del cartílago auricular (condritis auricular) y síndrome vertiginoso con evolución clínica satisfactoria al tratamiento inmunosupresor con glucocorticoides. Conclusiones: Es difícil definir si existe asociación entre la policondritis recidivante y la leucemia mieloide aguda, la quimioterapia o la sumatoria de las dos noxas. Una vez que se establece el diagnóstico se debe iniciar oportunamente la administración de glucocorticoide a altas dosis, ya que pudieran aparecer complicaciones como la necrosis del cartílago y la pérdida de la región afectada. En contraste, el uso de los glucocorticoides tiene una excelente respuesta con modulación completa de la enfermedad, tal como se muestra en el caso presentado(AU)

Relapsing polychondritis is a systemic, chronic and autoimmune disease characterized by the inflammation of cartilaginous tissues. This disease is associated in a few cases with malignant hematological diseases. We present a case of a patient with relapsing polychondritis and concomitantly with acute myeloid leukemia. A 26-year-old female patient, with cutaneous affection as initial manifestation categorized as erythema nodosum. Then she was diagnosed with acute myeloid leukemia. In the aplasia post-chemotherapy phase, the patient developed bilateral inflammation of the ear cartilage (auricular chondritis) and a vertiginous syndrome with satisfactory clinical evolution to immunosuppressive treatment with glucocorticoids. Conclusion: Relapsing polychondritis usually presents with cartilaginous involvement, such as bilateral atrial chondritis, as shown in the case. Early diagnosis and timely treatment are necessary to achieve a good clinical response. Subsequent studies are necessary to evaluate the association between relapsing polychondritis and hematological alterations such as acute myeloid leukemia and the use of chemotherapy(AU)

Panniculitides of particular interest to the rheumatologist

Abstract The panniculitides remain as one of the most challenging areas for clinicians, as they comprise a heterogeneous group of inflammatory diseases involving the subcutaneous fat with potentially-shared clinical and histopathological features. Clinically, most panniculitides present as red edematous nodules or plaques. Therefore, in addition to a detailed clinical history, a large scalpel biopsy of a recent-stage lesion with adequate representation of the subcutaneous tissue is essential to specific diagnosis and appropriate clinical management. Herein we review the panniculitides of particular interest to the rheumatologist.

Lepra dimorfa lepromatosa conyugal / Lepromatous dimorphic leprosy in spouses

Leprosy is a contagious, chronic infectious disease caused by Mycobacterium leprae. The immune response of the host to this bacillus is variable, determining different clinical forms of the same disease. Between the Lepromatous and Tuberculoid spectra, both stable clinical forms, the Dimorfo type can be presented, with great immunological instability, determining clinical characteristics, according to the pole to which most approaches. Leproatous dimorphic leprosy is characterized by brwn and violet macules, large number of lesions and less definition at its edges, variable sizes and alteration of sensitivity. Conjugal leprosy occurs in very few cases, knowing that intimate contaqct for a long time is an important factor, but has also demonstrated the fundamental role of immunity and genetics to acquire and develop the disease. We present two cases of lepromatous dimorphic leprosy in spouses, with 20 years of cohabitation, in which the same clinical presentation was found. Ths is an infrequent fact, given the low infectivity of the pathogen and the multiple varieties that could occur.

Eritema nudoso asociado a parasitismo por Ascaris lumbricoides. Presentación de caso / Nudose erythema associated to Ascaris lumbricoides parasitism: Cases presentation

Introducción: El Eritema nudoso es una paniculitis, de relativa frecuencia, que se expresa como manifestación de trastornos internos de gran envergadura, como las enfermedades del tejido conectivo, las enfermedades infecciosas y el cáncer. Es por ello, que los pacientes que lo presenten, deben ser estudiados cuidadosamente en busca de la causa. Objetivo: Presentar un caso clínico de Eritema nudoso resaltando el diagnóstico de la causa parasitaria y su tratamiento. Presentación de Caso: Se muestra el caso de una paciente femenina de 29 años, de raza blanca, residente en un municipio rural (Jatibonico), profesora de escuela primaria, sin antecedentes patológicos, quien acude a consulta por eritema elevado muy doloroso en la superficie anterior de ambos miembros inferiores, malestar general y artralgias. Se le diagnosticó clínicamente un eritema nudoso, y durante varios meses se realizaron complementarios para establecer la posible causa; se encontró solo un parasitismo intestinal por Ascaris lumbricoides. Recibió tratamiento médico con antiparasitarios, y desapareció el eritema. Conclusiones: El diagnóstico clínico certero, más la búsqueda constante de la causa del eritema nudoso y el tratamiento del parasitismo encontrado, llevaron a la solución del problema de la paciente. El eritema nudoso siempre debe ser estudiado por la posibilidad de ser un síndrome reactivo a procesos grave(AU)

Introduction: Nudose erythema is a panniculitis, of relative frequency, that it is expressed like a manifestation of internal disorders of great significance, like the illnesses of the connective tissue, the infectious diseases and the cancer. So the patients that show it, must be studied carefully in search of the cause. Objective: To Present a nudose erythema clinic case highlighting the diagnose of parasitical cause. Cases presentation: Is show the case of a white female patient, 29 years old, resident at rural municipality (Jatibonico), elementary school teacher, without pathological past health history, that assist at the consult for nodular due to a high very painful erythema on the anticus surface of both inferior members, general discomfort and arthralgia. Was clinically diagnosed a nudose erythema, and during several months were performed complementary to establish the possible cause, finding only an intestinal parasitism for Ascaris lumbricoides. He received medical treatment with antiparasitcs, disappearing the erythema. Conclusions: The accurate diagnostic, furthermore, a constantly cause searching of the cause of the nudose erythema plus the treatment of parasitism found, solve the patients problem. Nudose erythema always must be studied due to the possibility to be a reactive syndrome of seriously ill process(AU)

Eritema nodoso: Causas más prevalentes en pacientes que se hospitalizan para estudio, y recomendaciones para el diagnóstico / Erythema nodosum: Analysis of 91 hospitalized patients

Background: Erythema Nodosum (EN) is an acute nodular erythematous cutaneous eruption. It is presumed to be a hypersensitivity reaction and it may be idiopathic, or occur in association with diverse diseases and medications. Aim: To identify the main etiologies of EN among patients admitted to a medicine service of a clinical hospital. Material and Methods: Analysis of medical records of patients discharged with the diagnosis of EN during a ten years period. Patients were considered to have secondary EN when an underlying condition was found, and to have idiopathic EN when no such condition was found. Results: One hundred twenty nine patients were identified, but 91, aged 38 ± 14 years (86% females) had available clinical information. The etiology was idiopathic in 32% and secondary in 68% of patients. The leading etiologies were post-Streptococcal in 32%, followed by sarcoidosis in 11%, primary tuberculosis in 7%, Mycoplasma infection in 3%, Bartonella infection in 3%, Behçet’s syndrome in 2%, inflammatory bowel disease in 2%, drugs in 1% and other etiologies in 8%. Secondary cases of EN had higher levels of C Reactive Protein and leucocytes than idiopathic cases. Conclusions: The distribution of causes in our study population were similar to those reported in the literature (With smaller proportion of idiopathic), as was the man/woman (1/6) ratio, and the preponderance of cases in winter and spring. Infectious diseases were the leading causes of EN in this group of patients, and a reasonable initial approach in the hospital should include a diligent medical history and physical examination, complete blood count, ESR, titles ASO, PPD tuberculin skin test, chest X-ray or CT scan and, where deemed appropriate, specific autoimmune and infectious serology.

Trombosis de senos venosos cerebrales en la enfermedad de Behçet / Cerebral venous sinus thrombosis in Behcet's disease

La enfermedad de Behçet es una vasculitis sistémica inmunomediada que afecta los pequeños vasos sanguíneos y se presenta frecuentemente con ulceraciones de las membranas mucosas y síntomas oculares. Se presentó un paciente masculino de 25 años de edad, con antecedentes de úlceras bucales y genitales recurrentes, foliculitis, eritema nudoso, lesiones papulo-pustulosas, el cual tenía, desde 3 meses antes de su presentación en nuestro servicio, manifestaciones clínicas compatibles con un síndrome de hipertensión endocraneana benigna que no logra una evolución favorable con el tratamiento. Mediante la angio-TAC de cráneo se identificó una trombosis de senos venosos cerebrales. Los hallazgos clínicos y radiológicos son compatibles con una enfermedad de Behçet(AU)

Behcet's disease is an immune-mediated systemic vasculitis that affects small blood vessels and it frequently presents with ulceration of the mucous membranes and eye symptoms. A 25 year-old male patient is presented with history of recurrent cold sores and genital folliculitis, erythema nodosum, papular-pustular lesions. For three months before submission to our service, this patient had clinical manifestations compatible with benign intracranial hypertension syndrome that fails favorable evolution with treatment. By skull venuos CTA, venous sinus cerebral thrombosis was identified. Clinical and radiological findings are compatible with Behcet's disease(AU)

Manifestaciones nasales de la lepra / Nasal manifestations of leprosy

Introducción: la lepra es una enfermedad crónica infecciosa, causada por Mycobacterium leprae, que se manifiesta mediante el desarrollo de lesiones granulomatosas específicas y neurotróficas en piel, membranas mucosas, nervios, ojos y vísceras. Objetivo: destacar, casuísticamente, lo más relevante de la Lepra nasal que sea de utilidad para el diagnóstico precoz de esta enfermedad por los médicos de la Atención Primaria de Salud. Métodos : estudio descriptivo de corte transversal y retrospectivo realizado por el Servicio de Otorrinolaringología del Policlínico Docente "Carlos Manuel Portuondo", durante el periodo Enero de 2010 a Enero 2012. El Universo estuvo comprendido por 106 pacientes del área de Marianao diagnosticados de lepra por el Servicio de Dermatología del Hospital "Carlos Juan Finlay", la muestra quedó constituida por 90 casos que presentaron patología nasosinusal. Resultados: 90 casos presentaron patología nasosinusal. Fue muy frecuente el hallazgo de lesiones nasales en pacientes hansenianos. Conclusiones: el síntoma más comúnmente referido como antecedente fue la obstrucción nasal, seguida por el de epistaxis o sangramiento nasal. La única forma clínica en la que hemos encontrado la destrucción total del septum nasal fue la lepromatosa.

Introduction: leprosy is a chronic infectious disease caused by Mycobacterium leprae, which is manifested by the development of specific and neurotrophic granulomatous lesions in skin, mucous membranes, nerves, eyes and viscera. Objective: highlight casuistically is the most relevant knowledge of nasal leprosy for helping early diagnosis of this disease by doctors at Primary Health Care. Methods: adescriptive cross-sectional and retrospective study was conducted by the Department of Otorhinolaryngology at Carlos Manuel Portuondo Polyclinic, from January 2010 to January 2012. The universe was comprised of 106 patients from Marianao area diagnosed with leprosy by the dermatology service at Carlos Finlay Hospital. The sample was composed of 90 cases with sinonasal pathology. Results: 90 cases showed sinus pathology. Nasal lesions were very common finding in leprosy patients. Conclusions: The most commonly referred symptom as antecedent was nasal obstruction, followed by epistaxis or nasal bleeding. Lepromatous was only clinical way in which we found total destruction of the nasal septum

Sarcoidosis aguda: variante de Síndrome de Lõfgren sin eritema nodoso / Acute sarcoidosis: erythema nodosum-free variant of Lõfgren’s Syndrome

El síndrome de Lõfgren, es una variante aguda de la sarcoidosis, que se caracteriza por fiebre, eritema nodoso, adenomegalias hiliares pulmonares y artritis. En general, tiene un curso benigno y autolimitado, que contrasta con las formas crónicas que requieren uso de corticoides y tienen tendencia a la recidiva. Se describe aquí el caso clínico de un paciente joven, de sexo masculino, con artritis pero sin eritema nodoso, lo que dificultó el planteo diagnóstico de síndrome de Lõfgren. Se realiza además una breve descripción comparativa entre la presentación clínica de la sarcoidosis crónica y el síndrome de Lõfgren...

Meningoencefalite linfomonocitária crônica, oligoartrite e eritema nodoso: relato de síndrome de Baggio-Yoshinari de longa e recorrente evolução / Chronic lymphomonocytic meningoencephalitis, oligoarthritis and erythema nodosum: report of Baggio-Yoshinari syndrome of long and relapsing evolution

A borreliose humana brasileira, também conhecida como Síndrome de Baggio-Yoshinari (SBY), é uma enfermidade infecciosa própria do território brasileiro, transmitida por carrapatos não pertencentes ao complexo Ixodes ricinus, causada por espiroqueta do gênero Borrelia e que apresenta semelhanças clínicas e laboratoriais com a Doença de Lyme (DL). A SBY distingue-se da DL por apresentar evolução clínica prolongada, com episódios de recorrência e importante disfunção autoimune. Descreveremos o caso de uma paciente jovem, que desenvolveu progressivamente durante cerca de um ano oligoartrite de grandes articulações, seguida de distúrbio do cognitivo, meningoencefalite e eritema nodoso. O diagnóstico foi firmado devido à concomitância de queixas articulares e neurológicas com sorologia positiva para Borrelia burgdorferi sensu stricto. A paciente foi medicada com ceftriaxone 2 g/EV/dia por 30 dias, seguido de dois meses de doxiciclina 100 mg duas vezes ao dia. Houve remissão dos sintomas e normalização dos exames sorológicos para a borreliose. A SBY é uma zoonose emergente descrita apenas no Brasil, cuja frequência tem crescido bastante, e que, em razão das importantes diferenças nos aspectos epidemiológicos, clínicos e laboratoriais em relação à DL, merece especial atenção da classe médica do país. Trata-se de zoonose camuflada e de difícil diagnóstico, mas este deve ser perseguido com tenacidade, pois a enfermidade responde aos antibióticos no estágio inicial, podendo evoluir com sequelas neurológicas e articulares nos casos reconhecidos tardiamente ou recorrentes.

The Brazilian human borreliosis, also known as Baggio-Yoshinari Syndrome (BYS), is a tickborne disease but whose ticks do not pertain to the Ixodes ricinus complex. It is caused by Borrelia burgdorferi sensu lato microorganisms and resembles clinical and laboratory features of Lyme disease (LD). BYS is also distinguished from LD by its prolonged clinical evolution, with relapsing episodes and autoimmune dysfunction. We describe the case of a young female who, over one year, progressively presented with oligoarthritis, cognitive impairment, menigoencephalitis and erythema nodosum. Diagnosis was established by means of the clinical history and a positive serology to Borrelia burgdorferi sensu strictu. The patient received Ceftriaxone 2 g IV/day during 30 days, followed by 2 months of doxicycline 100 mg bid. Symptoms remitted and the Borrelia serology tests returned to normality. BYS is a new disease described only in Brazil, which has a raising frequency and deserves the attention from the country´s medical board because of clinical, epidemiological and laboratory differences from LD. Despite the fact that it is a hard-to-diagnose zoonosis, it is important to pursuit an early diagnosis because the symptoms respond well to antibiotics or it might be resistant to treatment and may evolve to a chronic phase with both articular and neurological sequelae.

Síndrome de Lõfgren / Lõfgren’s Syndrome

A sarcoidose é uma doença crônica granulomatosa, de origem desconhecida, que pode envolver praticamente qualquer órgão, mas na qual a presença de artrite é incomum. Apresentamos um caso no qual a artrite foi o achado inicial, associada ao eritema nodoso, levando à investigação e ao diagnóstico da síndrome de Lõfgren. Nessa forma de apresentação da sarcoidose, além da artrite ou artralgias e do eritema nodoso, também deve estar presente a linfadenopatia hilar bilateral como critério diagnóstico. A síndrome de Lõfgren é chamada algumas vezes de sarcoidose aguda, estando geralmente associada com um bom prognóstico e resolução espontânea.

Sarcoidosis is a chronic granulomatous disease, of unknown origin, that may involve virtually any organ, but in which the presence of arthritis is uncommon. Here we present a case in which arthritis was the first finding, associated with erythema nodosun, leading to the investigation and diagnosis of Lõfgren Syndrome. In this form of sarcoidosis presentation, in addition to arthritis or arthralgia and erythema nodosun there must be bilateral hilar lymphadenopathy as a diagnostic criterion. Lõfgren’s syndrome is sometimes called acute sarcoidosis, usually being associated with good prognosis and spontaneous resolution.

Presentación clínica de la tuberculosis infantil / Clinical presentation of childhood tuberculosis

Establecer el diagnóstico de tuberculosis (TBC) en niños no es fácil. Muchas de sus manifestaciones son inespecíficas, por lo que requiere alto índice de sospecha. Mas aún, en nuestro medio, la TBC es una condición infrecuente. Este artículo brinda una revisión en torno a los conceptos contacto y primoinfección, ilustrando de manera breve algunos escenarios clínicos como TBC pulmonar primaria progresiva, TBC ósea y eritema nodoso de nuestra práctica diaria.

Eritema nodoso / Erythema Nodosum

Os autores fazem uma revisão bibliográfica sobre eritema nodoso, incluindo suas diversas causas, manifestações clínicas, investigação e diagnósticos diferenciais. É enfatizada que eritema nodoso pode ser a manifestação cutânea de uma doença sistêmica, logo, essa situação deve ser afastada

Erythema nodosum as a manifestation of HIV infection.

Various musculoskeletal syndromes have been well described in patients infected with the human immunodeficiency virus (HIV). Surprisingly, erythema nodosum, an inflammation of the adipose tissue of the skin, has rarely been described. We report a 24-year-old known case of HIV infection, who developed fever and multiple tender subcutaneous nodules that were proven to be erythema nodosum. The patient also had polymyositis. She responded well to a high dose of corticosteroids. Erythema nodosum should be listed as possible the rheumatic manifestation of HIV infection.

Lepra urbana: un llamado de atención / Urban leprosy: call for attention

Se presenta una paciente de sexo femenino de 16 años de edad, oriunda de Capital Federal y residente en esta ciudad desde su nacimiento, que consulta por la presencia de nódulos eritemato-violáceos localizados principalmente en cara anterior de piernas y muslos, sin otro compromiso cutáneo, de mucosas o faneras. El diagnóstico final fue de lepra lepromatosa en reacción: eritenma nudoso leproso (ENL). La paciente tenía 2 tíos, un primo y una abuela, todos residentes en Capital Federal, afectados de lepra. Con este motivo, se discute un nuevo fenómeno epidemiológico que es la Lepra Urbana y la importancia de su consideración en el diagnóstico y tratamiento precoz de la enfermedad, sin esperar la presencia de estigmas crónicos