Epitelioma cuniculatum asociado al virus papiloma humano. Presentación de caso / Epithelioma cuniculatum associated with human papillomavirus. Case presentation

Introducción: El epitelioma cuniculatum es una variante infrecuente del carcinoma epidermoide, es el subtipo cutáneo del carcinoma verrugoso, que afecta al pie y que puede estar relacionado con el virus papiloma humano (VPH). El hecho de que la lesión inicial sea a menudo confundida con una verruga plantar dilata su diagnóstico y tratamiento. Objetivo: reportar un caso poco frecuente de un paciente con carcinoma cuniculatum del pie derecho, relacionado con VPH, de larga evolución, que se extendió formando una masa vegetante, afectando los tres últimos dedos. Presentación del caso: se presentó un paciente masculino blanco (fototipo III) de 69 años de edad, que en tres ocasiones se le habían resecado verrugas plantares en el pie derecho, presentó una evolución tórpida con aparición de lesión ulcerosa de 2 centímetros de diámetro, con biopsia positiva a carcinoma epidermoide asociado a VPH, al cual se le realizó desarticulación con bordes de seguridad de la lesión. Conclusiones: Se presentó un raro caso de carcinoma epidermoide del pie, relacionado con una verruga plantar asociada a VPH, la cual inicialmente fue extirpada quirúrgicamente de forma inadecuada(AU)

Introduction: Epitelioma cuniculatum is an unusual variant of epidermoid carcinoma. It is the subtype of cutaneous verrucous carcinoma that affects the foot and can be associated with the human papillomavirus (HPV). The lesion is frequently confused with plantar warts, delaying its diagnosis and treatment. Objective: To present an uncommon case of a patient with long history of epitelioma cuniculatum of the right foot associated with HPV, which spread out forming a vegetative mass affecting the last three toes. Case presentation: A sixty-nine-year-old white male patient (phototype III) that in three different moments had undergone excision of plantar warts in the right foot presented a torpid evolution with the appearance of ulcerative lesion of two centimeters in diameter. The biopsy was positive to epidermoid carcinoma associated with HPV; so, resection including safety margins around the tumor was performed. Conclusion: An unusual case of epidermoid carcinoma of the foot related to a plantar wart associated with HPV, which was initially removed by inadequate surgery, is presented(AU)

Lipoblastoma: una causa inusual de tumoración del pie en niños / Lipoblastoma: An unusual cause of foot lump in children

Los tumores óseos y de partes blandas localizados en el pie son muy poco frecuentes. El lipoblastoma es una neoplasia benigna de partes blandas rara que se presenta exclusivamente en la población pediátrica, con predilección por el sexo masculino. Su asiento preferente son las extremidades, pero raramente afecta el pie. Presentamos un caso de lipoblastoma de pie en un niño de 13 meses de edad y una revisión de la bibliografía. Nivel de Evidencia: IV

Bone and soft tissue tumors of the feet are uncommon. Lipoblastoma is a rare benign soft tissue tumor, exclusive to the pediatric population, with predilection for boys. Lipoblastomas most commonly occur in the extremities, but rarely affect the foot. We present a case of lipoblastoma occurring in the foot of a 13-month-old boy, as well as our literature review. Level of Evidence: IV

Acrometástasis óseas, serie de casos y revisión de la literatura / Bone acrometástasis, case series and literature review

Resumen: Las acrometástasis se definen como metástasis óseas localizadas distales al codo y la rodilla. Su prevalencia es muy baja, aproximadamente el 0,1% de todas las metástasis óseas y se presentan en pacientes con enfermedad avanzada y son indicador de mal pronóstico. Hasta en el 10% de los casos se presentan como el primer signo de neoplasia oculta. Su forma de presentación clínica y radiológica es inespecífica, lo que genera retraso en su diagnóstico y tratamiento. La resonancia magnética es la imagen de elección para el diagnóstico. El tratamiento en la mayoría de los casos es paliativo. Presentamos cuatro pacientes con acrometástasis y una revisión de la literatura.

Abtract: Acrometastasis are defined as localized bone metastases distal to the elbow and knee. Its prevalence is very low, approximately 0.1% of all bone metastases and they present in patients with advanced disease and are considered indicators of poor prognosis. In up to 10% of cases are the first sign of undiagnosed neoplasia. Its clinical and radiological presentation is non-specific which generates delays in its diagnosis and treatment. Magnetic resonance is the image of choice for diagnosis. The treatment in most cases is palliative. We present four patients with acrometastasis and a review of the literature.

Vasculopatia livedoide tratada com rivaroxabana / Livedoid vasculopathy treated with rivaroxaban

A vasculopatia livedoide é uma doença rara caracterizada pela oclusão da microvasculatura da derme, originando lesões maculosas que, posteriormente, podem evoluir para úlceras e cicatrizes atróficas. Como um fenômeno vaso-oclusivo, o tratamento geralmente é realizado com antiplaquetários e fibrinolíticos. O presente relato descreve o caso de uma paciente refratária à terapia convencional, que obteve regressão da doença utilizando a rivaroxabana, um fármaco inibidor seletivo do fator Xa. (AU)

Livedoid vasculopathy is a rare disease characterized by occlusion of the dermis microvasculature, leading to spotted lesions that can later develop into ulcers and atrophic scars. As a vaso- occlusive phenomenon, treatment is usually performed with antiplatelet and fibrinolytic agents. The present report describes the case of a female patient refractory to conventional therapy who presented disease remission using rivaroxaban, a selective factor Xa inhibitor drug. (AU)

Remitting seronegative symmetrical synovitis with pitting edema (rs3pe): una inusual causa de edema en el adulto mayor / Remitting seronegative symmetrical synovitis with pitting edema (RS3PE): an unusual cause of edema in the elderly

El RS3PE es una patología infrecuente de la esfera reumatológica que afecta a adultos mayores, manifestándose como poliartritis simétrica más edema con signos de fóvea. Si bien suele tener una excelente respuesta a corticoides, debe tenerse en considera-ción su asociación a neoplasias, lo cual determina el pronóstico de la enfermedad. Se presenta el caso de un varón de 75 años, con artritis y severo edema de extremida-des, el cual revirtió completamente con el uso de prednisona.

RS3PE is a rare rheumatological syndrome that affects older adults, manifesting as symmetrical polyarthritis and limbs edema. Although it usually has an excellent re-sponse to corticosteroids, its association with neoplasms must be taken into con-sideration, which determines the prognosis of the disease. We report the case of a 75-year-old man with arthritis and severe edema of limbs, which completely reversed with the use of prednisone.

Morfometría, planimetría y estereología en el hueso sesamoídeo distal en manos de equinos con y sin síndrome navicular / Morphometry, planimetry and stereology in the distal sesamoid bone in equine foot with and without navicular syndrome

El Síndrome Navicular (SN) es una patología claudicógena bilateral crónica, degenerativa y progresiva, que compromete alhueso sesamoídeo distal (HSD), labolsa podotroclear, ligamentosy a las superficies adyacentes al tendón del músculo flexor digitalprofundo en manos de equinos. La hipótesis de que las características morfológicas del HSD en la mano de equinos varían en aquellos que presentan SN fue evaluada en este estudio. Para determinar cambios morfológicos en el HSD en manos de equinos con SN se realizó un estudio morfométrico, planimétrico y estereológico. Fueron evaluados dos grupos: No Afectadas (n=11) y Síndrome Navicular (n=11). Se evaluaron variables tales como peso, volumen, mediciones lineales, área y parámetros estereológicos tales como densidad de número (NA), volumen (VV) y superficie (SV). Los resultados obtenidos indican que a pesar de existir un proceso patológico e inflamatorio en la región del HSD que induce cambios mesoscópicos y microscópicos atribuibles a SN, no lograrían modificar sus características macroscópicas.

Navicular Syndrome (NS) is a chronic, degenerative and progressive bilateral claudication pathology, compromising the distal sesamoid bone (DSB), the podotrochlear bursa, ligaments and adjacent surfaces of the tendon of the deep digital flexor muscle of equine foot. The hypothesis that morphological characteristics of HSB in hand of horses vary in those with SN was evaluated in this study. A study was carried out to determine the morphological changes in the DSB in 22 left foot of horses with NS. We realized morphometrical, planimetrical and stereological studies in two groups of horses feet: Not Affected (n=11) and Navicular Syndrome (n=11). The following variables were quantified: weight, volume, linear measurements, area and stereological parameters: densities of number (NA), volume (VV) and surface (SV). Results indicate that although there is a pathological and inflammatory process in the region of DSB which induces mesoscopic and microscopic changes attributable to SN, their gross morphological features were not modified.

Detección de alteraciones posturales en niños de 6 a 11 años en campaña del Hospital Nacional Arzobispo Loayza, 2012 - 2013 / Detection of postural alterations in children of 6 to 11 years at campaign organized by the National Hospital Arzobispo Loayza, 2012-2013

Se realizó la Detección de alteraciones posturales en niños de 6 a 11 años, en Campaña del Hospital Nacional Arzobispo Loayza, en la Institución Educativa Estatal No 1019 "Chavín" de Breña, donde fueron evaluados236 niños de ambos sexos, previa recepción del formato de Consentimiento informado llenado y firmado por sus padres. El objetivo de este trabajo fue conocer las alteraciones posturales en los escolares que participaron durante la Campaña. Para realizar la toma de datos durante la evaluación postural se empleó una "FICHA DE EVALUACIÓN POSTURAL PARA CAMPAÑA COMUNITARIA DEL HOSPITAL NACIONAL ARZOBISPO LOAYZA" previamente validada por 9 expertos, médicos especialistas en Medicina Física y Rehabilitación. Participaron en la evaluación 129 niños y 107 niñas. Las alteraciones posturales de columna vertebral (lordosis lumbar, escoliosis dorsal y cifosis dorsal) fueron las más frecuentes, constituyendo el 66.5 por ciento (157 escolares), seguidas de alteraciones de los pies (pies planos, talo valgo) que estuvieron presentes en el 64 por ciento de los evaluados (151 niños).

A detection of postural alterations in children of 6-11 years old was performed in the medical campaignorganized by the National Hospital Arzobispo Loayza in the library of the Public School Number 1019 "Chavin" located in Breña, where 236 children of both genders from this school were evaluated, previous consent of their parents through a document completed, approved and signed by them. The aim of this work was to detect the prevalence of postural disorders in children of this school. To collect information during the postural evaluation, it was necessary to use a "POSTURE EVALUATION FORM FOR THE COMMUNITY CAMPAIGN OF THE NATIONAL HOSPITAL ARZOBISPO LOAYZA" previously validated by nine experts, specialists in Physical Medicine and Rehabilitation. There were a total of 129 boys and 107 girls evaluated in this activity. Spinal Postural disorders (lumbar lordosis, scoliosis and kyphosis dorsal) were the most common, 66.5 per cent (157 cases), followed by feet abnormalities (flat feet, talus valgus) which were present in 64 per cent (151 children).

A case of peripheral gangrene and osteomyelitis secondary to terlipressin therapy in advanced liver disease

Variceal bleeding and hepatorenal syndrome (HRS) are serious and life-threatening complications of advanced liver disease. Terlipressin is widely used to manage both acute variceal bleeding and HRS due to its potency and long duration of action. The most severe (though rare) adverse event is ischemia. The present report describes the case of a patient with gangrene and osteomyelitis secondary to terlipressin therapy. A 71-year-old male with alcoholic liver cirrhosis (Child-Pugh B) and chronic hepatitis C was admitted due to a drowsy mental status. The patient had several experiences of orthopedic surgery. His creatinine level had gradually elevated to 4.02 mg/dL, and his urine output decreased to 500 mL/24 hr. The patient was diagnosed as having grade III hepatic encephalopathy (HE) and type II HRS. Terlipressin and albumin were administered intravenously to treat the HRS over 11 days. Although he recovered from the HE and HRS, the patient developed peripheral gangrene and osteomyelitis in both feet. His right toes were cured with the aid of rescue therapy, but his left three toes had to be amputated. Peripheral gangrene and osteomyelitis secondary to terlipressin therapy occur only rarely, and there is no specific rescue therapy for these conditions. Thus, attention should be paid to the possibility of ischemia of the skin and bone during or after terlipressin therapy.

Lipofibromatosis accompanied by several congenital anomalies, report of a rare case.

Lipofibromatosis is a rare tumor of infancy, which has been reported about 10 years ago, and since then very few reports have been published. This tumor has been reported in association with congenital anomalies such as macrosyndactyly, but there is no report of multiple congenital anomalies with lipofibromatosis in the English literature as far as our knowledge goes. Herein, we report a case of this tumor associated with syndactyly, bilateral complete cleft lip and palate, trigonocephaly, and atrial septal defect.

Primary cutaneous marginal zone lymphoma (immunocytoma like) with lymphoepithelioid or Lennert's lymphoma like involvement of nodes.

Primary cutaneous marginal zone lymphomas (PCMZL) have a wide range of morphology from tumors with monocytoid B cells to those composed entirely of plasma cells and the T-cell rich variants. We report a 60-year-old male with a PCMZL rich in plasma cells of the foot with a lymphoepithelioid-like pattern of dissemination to the lymph nodes posing problems in the diagnosis. The patient had a lesion on the dorsum of the foot which histologically revealed dense perivascular collections of lymphoid cells and plasma cells amidst fibrous tissue. Though the plasma cells did show light chain restriction, CD20 and CD3 did not reveal an overwhelming B/T-cell population and hence a diagnosis of a reactive process was offered. Subsequently the patient developed inguinal nodes with diffuse loss of architecture and replacement by epithelioid histiocytes and reactive T cells with few large B cells (lymphoepithelioid-like pattern). On pathology review it was realized that the two lesions may be related and clonality studies were asked for. The skin lesion showed clonally rearranged IgH receptor while the T-cell receptor rearrangement was negative. The patient developed disseminated disease and received six cycles of chemotherapy with partial response and 6 years after the initial presentation was alive with nonprogressive disease. Thus, the polymorphous background in PCMZL is evolving and an immunocytoma-like tumor can show a T-cell rich or Lennert's like growth pattern of spread and early recognition these odd patterns may aid in appropriate management of patients.

Necrolytic acral erythema: an unusual cutaneous presentation of hepatitis C virus infection

Necrolytic acral erythema [NAE] is a newly recognized dermatosis which has been regarded as early cutaneous marker of hepatitis C virus [HCV] infection. It presents as a well demarcated, dusky, symmetrically distributed erythematous to violaceous eruption with marked hyperkeratosis and lichenification associated with pruritus or burning on the dorsal aspects of feet extending to the toes. It shows clinical and histopathological resemblance to other necrolytic erythemas. We report a case of a-55-year-old woman with itchy hyperpigmented papules and plaques on the feet for the last 6 months. Histopathology showed the features of necrolytic acral erythema

Artroscopía de la articulación subastragalina: técnica quirúrgica, indicaciones, resultados y complicaciones / Subtalar joint arthroscopy: surgical technique, indications, results and complications

Introducción: El abordaje artroscópico para el tratamiento de la patología subastragalina se encuentra en pleno desarrollo. El propósito del presente trabajo es efectuar una descripción de las indicaciones, técnica quirúrgica, resultados y complicaciones en la realización de la artroscopía de la articulación subastragalina. Material y método: Se presenta 14 pacientes con patología de la articulación subastragalina, tratados durante los años 2003 al 2009. Se realizaron 11 artroscopías posteriores y 3 laterales. Seguimiento: 36 meses (R=15-69). Todos los pacientes fueron evaluados mediante el score AOFAS y a los 12 meses de la cirugía se les pregunto: 1- Si estaban satisfechos con el resultado de la cirugía. 2- Si volverían a realizar la intervención. Resultados: La indicación más frecuente de artroscopía para la articulación subastragalina ha sido en nuestra casuística la artrosis (35,71 por ciento). El score AOFAS promedio fue de 88,42 (R=46-100). El 78,58 por ciento de los pacientes estaban satisfechos con el resultado del procedimiento y un 85,72 por ciento volvería a operarse. Tuvimos una complicación de un paciente con hipoestesia del talón (7,14 por ciento). Conclusiones: La artroscopía de la articulación subastragalina es una herramienta diagnóstica y terapéutica segura, reproducible y confiable, exige un conocimiento de la anatomía artroscópica de la región y debe ser llevada a cabo por artroscopistas con experiencia. Diseño del estudio: Serie de casos. Nivel de evidencia: IV.

Preliminary Application of High-Definition CT Gemstone Spectral Imaging in Hand and Foot Tendons

OBJECTIVE: To assess the feasibility of visualizing hand and foot tendon anatomy and disorders by Gemstone Spectral Imaging (GSI) high-definition CT (HDCT). MATERIALS AND METHODS: Thirty-five patients who suffered from hand or foot pain were scanned with GSI mode HDCT and MRI. Spectrum analysis was used to select the monochromatic images that provide the optimal contrast-to-noise ratio (CNR) for tendons. The image quality at the best selected monochromatic level and the conventional polychromatic images were compared. Tendon anatomy and disease were also analyzed at GSI and MRI. RESULTS: The monochromatic images at about 65 keV (mean 65.09 +/- 2.98) provided the optimal CNR for hand and foot tendons. The image quality at the optimal selected monochromatic level was superior to conventional polychromatic images (p = 0.005, p 0.05), compression (chi2 = 0.5, p > 0.05), absence (chi2 = 0, p > 0.05) and rupture (chi2 = 0, p > 0.05). GSI was significantly less sensitive than MRI in displaying tendon adhesion (chi2 = 4.17, p < 0.05), degeneration (chi2 = 4.17, p < 0.05), and tendinous sheath disease (chi2 = 10.08, p < 0.05). CONCLUSION: GSI with monochromatic images at 65 keV displays clearly the most hand and foot tendon anatomy and disorders with image quality improved, as compared with conventional polychromatic images. It may be used solely or combined with MRI in clinical work, depending on individual patient disease condition.

Necrosis cutánea por tratamiento anticoagulante oral: caso clínico / Cutaneous necrosis caused by acenocumarol: case report

Cutaneous necrosis is a rare but serious complication, among patients treated with warfarin or acenocumarol derivatives. We report a 71 years old female with a history of deep venous thrombosis, receiving acenocumarol for three months. The treatment was discontinued, but had to be restarted, due to a new episode of thrombosis. Three days after restarting acenocumarol, the patient consulted for ecchymosis and pain of the right foot. At physical examination, there was distal cyanosis and absence of distal pulses. The patient was subjected to an embolectomy with the suspicion of an acute arterial occlusion, but no emboli were found. Due to the possibility of a cutaneous necrosis caused by Acenocumarol, the medication is discontinued. The cutaneous lesions progressed and eight days after the failed embolectomy, a gangrene of the right foot was diagnosed. The patient did not accept amputation dying fourteen days after the first intervention.

A propósito un caso registrado, se resume la historia clínica y se revisa la literatura, dada la escasa frecuencia de esta complicación derivada del tratamiento por anticoagulantes orales. La necrosis cutánea es un evento adverso raro, pero serio, de la anticoagulación con derivados de acenocumarol o warfarina. Se comunicó por primera vez en 1943. La incidencia de la necrosis cutánea inducida por anticoagulantes orales es de 0,01 al 0,1 por ciento de los pacientes tratados. El número de casos publicados en el mundo es de aproximadamente 300, y menos de 100 en lengua inglesa en las últimas tres décadas. Este trabajo reporta el caso de una paciente que presenta necrosis cutánea en hombro izquierdo y pierna derecha.

Rearfoot alignment and medial longitudinal arch configurations of runners with symptoms and histories of plantar fasciitis

OBJECTIVE: To evaluate and compare rearfoot alignment and medial longitudinal arch index during static postures in runners, with and without symptoms and histories of plantar fasciitis (PF). INTRODUCTION: PF is the third most common injury in runners but, so far, its etiology remains unclear. In the literature, rearfoot misalignment and conformations of the longitudinal plantar arch have been described as risk factors for the development of PF. However, in most of the investigated literature, the results are still controversial, mainly regarding athletic individuals and the effects of pain associated with these injuries. METHODS: Forty-five runners with plantar fasciitis (30 symptomatic and 15 with previous histories of injuries) and 60 controls were evaluated. Pain was assessed by a visual analogue scale. The assessment of rearfoot alignment and the calculations of the arch index were performed by digital photographic images. RESULTS: There were observed similarities between the three groups regarding the misalignments of the rearfoot valgus. The medial longitudinal arches were more elevated in the group with symptoms and histories of PF, compared to the control runners. CONCLUSIONS: Runners with symptoms or histories of PF did not differ in rearfoot valgus misalignments, but showed increases in the longitudinal plantar arch during bipedal static stance, regardless of the presence of pain symptoms.