Atrofia branca de Milian / Atrofie blanche

A vasculopatia livedoide é uma doença cutâneo-vascular que surge devido à oclusão trombogênica de vasos da derme. Apresenta-se por meio de máculas ou pápulas eritematosas e purpúricas, em membros inferiores, que podem levar à ulceração dolorosa crônica e recorrente. Com a evolução, pode haver cicatrização, o que leva ao aparecimento de áreas de fibrose e cicatrizes atróficas, irregulares e esbranquiçadas, dando nome à patologia. Relata-se o caso de uma paciente com vasculopatia livedoide de acometimento de membros inferiores. (AU)

Livedoid vasculopathy is a vascular skin disease resulting from thrombogenic occlusion of dermal blood vessels. It presents with erythematous, purpuric macules or papules on the lower limbs, which can lead to chronic and recurrent painful ulceration. With its progression, there may be scarring leading to the appearance of areas of fibrosis and atrophic, irregular, and whitish scars, which gave this name to the pathology. The case of a patient with livedoid vasculopathy affecting the lower limbs is reported. (AU)

Case for diagnosis. Diffuse ulcerated nodular lesions

Abstract Langerhans cell histiocytosis is a rare clonal proliferative disease, characterized by the infiltration of one or multiple organs by histiocytes. Due to the diversity of signs and symptoms, the diagnosis of this disease is often late. The estimated incidence in adults is one to two cases per million, but the disease is probably underdiagnosed in this population. This report presents a case of disseminated Langerhans cell histiocytosis. The authors highlight the most characteristic aspects of this rare and heterogeneous disease, which usually presents as a challenging clinical diagnosis.

Fenómeno de Lucio: a propósito de un caso / Lucio's phenomenon: a case report

Se presenta caso de paciente masculino de 67 años de edad, fototipo III, con antecedentes patológicos personales de lepra lepromatosa en tratamiento, que acude a consulta especializada de Dermatología en el Hospital Guillermo Fernández Baquero (La Habana, Cuba) por lesiones ulcerosas diseminadas. Se realizan complementarios y se concluye caso como fenómeno de Lucio. Resaltando la infrecuencia de este eritema necrosante y la severidad de los estados reactivos de la lepra pues son procesos distintos pero destructores de los tejidos, supuestamente dirigidos por el sistema inmunológico que aumentan en gran medida la morbimortalidad de esta enfermedad

A case of a 67 year old male patient, phototype III, with a personal pathological history of lepromatous leprosy in treatment is presented at a specialized dermatology clinic at Guillermo Fernández Vaquero hospital for disseminated ulcerative lesions. Complementary are performed and case is concluded as a phenomenon of Lucio. Highlighting the infrequency of this necrotizingerythema and the severity of the reactive states of leprosy are different but destructive processes of the tissues, supposedlydirected by the immune system that greatly increase the morbidity and mortality of this disease.

Glicose como causa e tratamento de necrose cutânea / Glucose as a cause of and treatment for cutaneous necrosis

A escleroterapia continua sendo um dos procedimentos mais executados pelos cirurgiões vasculares brasileiros. O conhecimento das suas complicações é imprescindível para que possamos evitá-las. Os efeitos colaterais graves desse método de tratamento para as telangiectasias dos membros inferiores são raros e frequentemente associados a um erro técnico ou à dosagem injetada. São predominantemente locais, apresentando-se, algumas vezes, como uma situação de difícil resolução. Relatamos um caso de formação de necrose cutânea após escleroterapia química com glicose hipertônica (75%) e sua cicatrização utilizando preparação tópica contendo vaselina e glicose 60%, cujo resultado estético foi satisfatório

Sclerotherapy remains one of the procedures most frequently performed by Brazilian vascular surgeons. Knowledge of its complications is indispensable to enable us to avoid them. The severe side effects of this method of treatment for telangiectasias of the lower limbs are rare and are often associated with technical errors or the dose injected. Complications are predominantly local, but are sometimes difficult to resolve. We report a case of formation of cutaneous necrosis after chemical sclerotherapy using hypertonic glucose (75%), which healed when treated with a topical preparation containing vaseline and 60% glucose, with satisfactory esthetic results

Prognostic factors for metastasis in cutaneous melanoma

Abstract: Background: Melanoma is a malignant neoplasia that shows high mortality when diagnosed in advanced stages. Early identification of high-risk patients for the development of melanoma metastases is the main strategy to reduce mortality. Objective: To assess the influence of eight epidemiological and histopathologic features on the development of metastases in patients diagnosed with primary cutaneous melanoma. Methods: Our historical cohort comprised patients with invasive primary cutaneous melanoma seen between 1995 and 2012 at a public university hospital and a private oncologic surgery institution in Southeastern Brazil. The following variables were analyzed: gender, age, family history of melanoma, site of the primary tumor, clinical and histologic subtype, Breslow thickness, histologic ulceration and the mitotic index. Kaplan-Meier univariate test and multivariate Cox proportional hazard analysis were used to assess factors associated with disease-free survival. Results: Five hundred and fourteen patients were enrolled. The univariate analysis identified the following significant risk factors: gender, age, site of the tumor, clinical and histologic subtype, Breslow thickness, histologic ulceration and mitotic index. Multivariate analysis included 244 patients and detected four significant prognostic factors: male gender, nodular clinical and histologic subtype, Breslow thickness > 4mm, and histologic ulceration. The mitotic index was not included in this analysis. Study limitations: Small number of patients in multivariate analysis. Conclusions: The following prognostic factors to the development of melanoma metastasis were identified in the study: male gender, nodular histologic subtype, Breslow thickness > 4mm and ulceration.

Manifestaciones mucocutáneas de intoxicación por metotrexato / 4pp Mucocutaneous manifestations of methotrexate toxicity

El metotrexato es un antimetabolito análogo al ácido fólico que inhibe competitivamente la enzima dihidrofolato reductasa y timidilato sintetasa, indispensables para la síntesis de ADN y ARN. Se utiliza ampliamente en dermatología y sus efectos adversos en la piel y mucosas son variados, incluyendo reacciones leves y graves. Las erosiones y úlceras cutáneas como manifestación de citotoxicidad por metotrexato son infrecuentes y representarían un signo cutáneo temprano de pancitopenia por toxicidad medular secundaria a dicha droga. En la mayoría de los casos existen enfermedades cutáneas previas a la ulceración, principalmente psoriasis. En ausencia de dermatitis subyacente, la presencia de ulceraciones es excepcional. Se presentan ocho casos de pacientes con signos cutáneos de intoxicación por metotrexato, con y sin dermatosis previas. En la mayoría hubo asociación de mucositis y compromiso medular. Se recomiendan pautas de tratamiento.

Methotrexate is an antimetabolite analog to folic acid that competitively inhibits the enzyme dihydrofolate reductase and thymidylate synthetase, essential for the synthesis of DNA and RNA. It is widely used in dermatology and its adverse effects on the skin and mucous membranes are varied, including mild and severe reactions. The appearance of erosions and skin ulcers as a manifestation of methotrexate cytotoxicity are quite infrequent. These would represent an early cutaneous sign of pancytopenia due to marrow toxicity secondary to this drug. In most of the cases there are cutaneous diseases prior to ulceration, mainly psoriasis. In the absence of underlying dermatitis, the presence of ulcerations is very rare. We present eight cases of patients with cutaneous signs of methotrexate poisoning, with and without previous dermatoses. Most of them associated mucositis and bone marrow involvement. Treatment guidelines are recommended.

Úlceras genitales de Lipschütz: reporte de un caso pediátrico / Lipschütz ulcers: a pediatric case report

Las úlceras genitales son una patología poco frecuente en las consultas de pediatría, pero que generan gran ansiedad familiar. Las úlceras de Lipschütz son úlceras vulvares agudas, dolorosas y autolimitadas de causa desconocida. Aparecen en mujeres jóvenes que no han tenido relaciones sexuales previas o tras un período de abstinencia. Paciente de 10 años con úlceras vulvares dolorosas que, tres días antes de la aparición de las lesiones, había presentado un cuadro de deposiciones diarreicas y fiebre. Se realizó una anamnesis y exploración física detallada y se llevaron a cabo diferentes pruebas complementarias para descartar enfermedades infecciosas de origen venéreo y no venéreo, todas ellas negativas. Se indicó tratamiento sintomático, y se observó, al mes, una completa resolución del cuadro, por lo que se confirmó el diagnóstico de úlceras de Lipschütz.

Genital ulcers are a rare entity in pediatric consultation, but they generate great family anxiety. Lipschütz ulcers are acute, painful, and self-limiting vulvar ulcers of unknown cause. These ulcers appear in young women who have not had previous sexual intercourse or after a period of sexual abstinence. We present a 10-year-old girl with painful vulvar ulcers with a 3-day history of diarrhea and fever before the onset of the lesions. A complete anamnesis and detailed physical examination were carried out and complementary tests were performed to investigate sexually and non-sexually transmitted disease; the results were negative. Symptomatic treatment was started; at one-month follow-up a complete resolution of ulcers confirmed the diagnosis of ulcer of Lipschütz.

Aspergilosis diseminada con importante afectación cutánea / Disseminated aspergillosis with significant skin involvement

La Aspergilosis es una infección micótica oportunista que afecta principalmente a pacientes inmunodeprimidos con neutropenia, en quienes produce a menudo enfermedad invasiva de curso fulminante. Las manifestaciones cutáneas de la Aspergilosis son infrecuentes, apareciendo en el 5 a 10% de los casos diseminados. Comunicamos un caso de Aspergilosis en una mujer adulta con neutropenia severa por enfermedad hematológica, con afectación pulmonar y sinusal, que presenta múltiples lesiones ulceronecróticas en piel y mucosas, con evolución fatal. Las lesiones mucocutáneas de la Aspergilosis no son específicas, obligan a varios diagnósticos diferenciales y, como en este caso, la biopsia para estudio histopatológico y micológico es necesaria para el diagnóstico.

Aspergillosis is an opportunistic fungal infection that primarily affects immunocompromised patients with neutropenia, in whom invasive disease often results in fulminant course. Cutaneous manifestations of aspergillosis are rare, occurring in 5-10% of cases scattered. We report a case of aspergillosis in an adult woman with severe neutropenia for hematologic disease, lung and sinus disease, having multiple ulceronecróticas skin lesions and mucous membranes, with fatal outcome. The mucocutaneous lesions of aspergillosis are nonspecific, forcing several differential diagnoses, and as in this case, the biopsy for histopathological and mycological study is required for diagnosis.

Esporotricosis linfocutánea en niños: a propósito de un caso / Lymphocutaneous sporotrichosis in children: apropos of a case

Introducción: La esporotricosis linfocutánea es una micosis subcutánea de evolución sub-aguda o crónica, que es más frecuente en adultos entre los 16 y 30 años de edad pero que también se presenta en la niñez, sobre todo en áreas rurales. Se caracteriza por nódulos que se reblandecen y luego se ulceran, lo cual constituye el chancro inicial. Dos o tres semanas después se observan nódulos eritematovioláceos, no dolorosos siguiendo el trayecto linfático regional. El diagnóstico definitivo se realiza al aislar el agente causal mediante cultivo. En nuestro país el tratamiento usual y eficaz sigue siendo el yoduro de potasio. Caso Clínico: Se presenta el caso de un paciente masculino de 2 años de edad, con dermatosis de 2 semanas de evolución con historia de trauma 2 semanas antes del inicio de las lesiones, caracterizada por úlcera costrosa en dorso de mano derecha con presencia de adenopatías blandas, no dolorosas siguiendo la cadena ganglionar de antebrazo y brazo derecho. Conclusiones: La esporotricosis puede presentarse a cualquier edad aún en niños tan pequeños como este paciente de 2 años. La solución saturada de yoduro de potasio es muy eficaz en el manejo de esta patología por lo que aunado a su bajo costo sigue siendo de elección en países en vías de desarrollo...

Síndrome trófico trigeminal: una causa infrecuente de úlceras faciales / Trigeminal trophic syndrome: a rare cause of facial ulceration

El síndrome trófico trigeminal (SST) es una rara causa de úlceras crónicas en cara. Se presenta con una tríada característica de úlceras faciales, parestesias y anestesia del área inervada por el nervio trigémino. Representa un doble desafío: diagnóstico, por la cantidad de diagnósticos diferenciales, y terapéuticos, por ser de muy difícil resolución. Se presenta un paciente de sexo masculino, con antecedentes de accidentes cerebrovascular con secula facial y ulceras correspondientes a este síndrome.

Neoplasia maligna en cicatriz de quemadura: úlcera de Marjolin: informe de dos casos y revisión de la literatura / Malignant neoplasm in burn scar: Marjolin's ulcer: report of two cases and review of the literature

BACKGROUND: Marjolin's ulcer forms part of a group of neoplasms that originate in a burn scar, a phenomenon associated with superficial tissue trauma. The frequency of Marjolin's ulcer is low and represents between 2 and 5% of all squamous cell carcinomas of the skin. This condition is found three times more frequently in men than in women and is thought to be more aggressive than conventional squamous cell carcinoma of the skin. CLINICAL CASES: We present two cases of squamous cell carcinoma that originated on a burn scar. 41 year old woman with gasoline burn on the left foot, 3 months old, in whom an exofitic ulcerated lesion on the right calcaneum region has evolved since she was 32 years old. Left transtibial amputation was decided. Another woman who started its suffering 9 years after a thorax burn with a progressive fungus lesion on the scar area. For its size and as it was a high degree neoplasia, surgical resection and radiotherapy to the zone of the primary with 50 Gy in 25 fractions was decided. CONCLUSIONS: Marjolin's ulcer usually occurs in old burn sites that were not skin grafted and were left to heal secondarily. Although it is believed that there is a latency period of 25-40 years after burn injury before the occurrence of malignancy, this may occur in a period as short as 3 months. Recurrence after radical surgery is 14.7%. Nonetheless, because of the aggressive behavior of this type of cancer, appropriate radical treatment allows an adequate control of the disease. Early grafting of the burn site can prevent the formation a malignant neoplasm. This condition should be suspected in a non-healing chronic ulcer on a burn scar.

Fibrohistiocitoma maligno (fibroxantosarcoma) de cuero cabelludo: a propósito de un caso / Histiocytoma malignant fibrous (Fibroxantosarcoma) of scalp: a purpose of a case

Los tejidos blandos comprenden los músculos, tendones, la grasa, el tejido fibroso, el tejido sinovial, los vasos y los nervios. Alrededor del 60 por ciento de los sarcomas de tejidos blandos se originan en los miembros, siendo 3 veces más frecuentes en los miembros inferiores que en los superiores. En 30 por ciento de los casos se localiza en el tronco y en 40 por ciento son retroperitoneales. En el resto del 10 por ciento se trata de tumores de cabeza y cuello. La entidad denominada fibrohistiocitoma comprenden un gran número de tumores calcificados anteriormente como fibrosarcomas o como variedades polimorfas de otras sarcomas, y se caracteriza por una mezcla de células fusiformes (fibrosas) y células redondas (histiocitarias) dispuestas en un patrón estoriforme, junto con abundantes células gigantes y zonas de polimorfismo. La importancia de los estudios de inmunohistoquímica en los tumores de partes blandas radica en la necesidad que tiene el patólogo de precisar el diagnóstico histopatológico de lesiones benignas y malignas pseudosarcomatosas o sarcomatosas y poder diferenciarlas de neoplasias de otro origen. Se trata de paciente masculino de 65 años quien consulta por presentar desde agosto del 2006, caracterizado por lesiones ulcerosa en cuero cabelludo sangrantes quién se le tomo una primera biopsia que reporta. La nueva Biopsia tomada en enero en este centro reporta Carcinoma Epidermoide moderadamente a poco diferenciado en región fronto parietal de cuero cabelludo recibe 1 ciclo de quimioterapia, se toma una biopsia nueva reportando su inmunohistoquímica Fibrohistiocitoma Maligno (fibroxantosarcoma)/Tumor de Cuero Cabelludo, en vista de resultado se planifica nueva quimioterapia, se observo mejoría satisfactoria en la lesión en cuero cabelludo, por lo que decide oncología y el servicio de Medicina Interna dar de alta y seguir sus quimioterapias por consulta externa.

Inusual presentación de un Linfoma B cutáneo en un paciente joven / Unusual presentation of a cutaneous B Lymphoma in a young male

Se reporta el caso de un paciente masculino de 23 años de edad, que se presenta con una úlcera de región latero cervical, única, sin compromiso del estado general. Se solicita estudio histopatológico de la lesión e inmunomarcación, con diagnóstico de Linfoma no Hodgkin B de células grandes cutáneos primarios. Se realiza una revisión sobre los Linfomas no Hodgkin B de células grandes cutáneos primarios, siendo anecdótica la presentación en pacientes jóvenes.

We report a case of a 23 year old male with a lateral cervical ulcer, without general involvement. Histophatological study and immunomarcation were positive to non Hodgkin Difuse Primary Cutaneous Large B-Cell Lymphoma. A revision was made about Primary Cutaneous B-Cell Lymphomas, being unusual this presentation in young people.

Cutaneous infection caused by Corynebacterium pseudodiphtheriticum: a microbiological report / Infecção cutânea causada por Corynebacterium pseudodiphtheriticum: relato microbiológico

We report here a rare case of cutaneous infection due to Corynebacterium pseudodiphtheriticum. The patient presented to the clinical laboratory with a skin ulcer on his left leg. Gram-stained preparation of the purulent secretion revealed the presence of numerous rod-shaped Gram-positive organisms in the absence of any other species. The organism was grown in pure culture on sheep blood agar and was further identified as C. pseudodiphtheriticum using a commercial identification system (API-Coryne, BioMérieux, France). The infection was successfully treated with ciprofloxacin. This case emphasizes the importance of the clinical microbiology laboratory in correctly identifying Gram-positive organisms obtained in pure culture from skin ulcers.

Reportamos o isolamento de Corynebacterium pseudodiphtheriticum de um caso de infecção cutânea. O paciente apresentou-se ao laboratório clínico com uma úlcera na perna esquerda. A coloração de Gram do material revelou a presença de bacilos Gram-positivos e ausência de outras espécies bacterianas. O organismo foi isolado em cultura pura no ágar sangue de carneiro e foi identificado como C. pseudodiphtheriticum através de um sistema de identificação comercial (API-Coryne, BioMérieux, França). A infecção foi tratada com sucesso através do uso de ciprofloxacina. Este caso reforça a importância do laboratório de microbiologia clínica na identificação de organismos Gram-positivos isolados de cultura pura de amostras de úlceras cutâneas.

Ulcera de Buruli en Tumbes. Presentación de un caso y revisión de la literatura / Ulcer of Buruli in Tumbes. A case report and literature review

La úlcera de Buruli es una enfermedad infecciosa endémica causada por Mycobacterium ulcerans. Se presenta en diversas formas, siendo la ulcerada la más discapacitante. El cuadro clínico fluctúa desde el nódulo indoloro hasta extensas lesiones ulceradas que pueden curar espontáneamente, pero muy lentamente. Presentamos el caso de un varón de 53 años con esta patología. Se revisan los aspectos diagnósticos, de tratamiento y pronósticos.

Reação reversa com vasculites granulomatosas e lesões cutâneas necrosantes e ulcerativas / Reversal reaction with granulomatous vasculities and necrotizing cutaneous lesions

Um indivíduo com 49 anos de idade recebe o diagnóstico de Hanseníase Virchoviana sub-polar. Ele referiu, durante os prévios 11 anos, sintomas, principalmente neurológicos, característicos de hanseníase, mas este diagnóstico não foi definido nos serviços médicos que freqüentou. Após 6 meses de poliquimioterapia passou a apresentar neurites que foram tratadas como reação tipo 2. Em um último episódio apresentou febre, mal estar, mialgias e lesões necróticas e ulcerativas nos membros, nádegas, dorso, pavilhão auricular esquerdo. O aspecto clínico destas lesões era semelhante as lesões observadas no fenômeno de Lúcio e no Eritema nodoso necrosante. As biópsias mostram alterações da microvasculatura superficial, necrose epidérmica e dérmica, similares a estas reações, mas as alterações básicas são vasculites granulomatosas no derma profundo e tecido celular sub-cutâneo. Estes aspectos clínicos e histopatológicos são interpretados e discutidos como reação tipo 1 (reação reversa) com envolvimento vascular predominante.