Aspects of Langerhans cells and TNF-α in the cutaneous immunity of anogenital warts

Abstract Background: Anogenital warts are the leading sexually transmitted infection in patients seeking care at specialized clinics. They may display a vast array of forms, according to the interaction of the virus with the host's immunity. Cellular immunity is the epithelium's main form of defense against the virus, involving an active participation of the Langerhans cells and pro-inflammatory cytokines such as TNF-α. Objective: To assess the epithelial immune response of anogenital warts in males, according to the number of lesions presented. Methods: This is a prospective, cross-sectional study carried out at the dermatology outpatient clinic in a tertiary hospital. We included male patients over 18 years of age without comorbidities who had anogenital condylomata and no previous treatments.In order to evaluate the local epithelial immunity, the lesions were quantified, then removed and employed in CD1a immunohistochemistry assays for assessing the morphometry and morphology of Langerhans cells; TNF-α; reaction was used for determining cytokine positivity in the epithelium. Results: 48 patients were included in the study. There was no statistically significant difference as to the number of Langerhans cells, in their morphology, or the presence of TNF-α. However, patients presenting with more Langerhans cells in the lesions had cells with a star-like and dendritic morphology, whereas in those with a lower cell count had cells with a rounded morphology and no dendrites (p < 0.001). Study limitations: Small number of patients analyzed. Conclusion: There was no difference in epithelial immunity between patients having few or many anogenital condyloma lesions as measured by the morphology and morphometry of Langerhans cells and TNF-α; positivity. Such an assessment employing immunity markers differing from the usual ones is expected to yield useful results.

New drugs, new challenges for dermatologists: mucocutaneous ulcers secondary to everolimus

Everolimus, a mammalian target of rapamycin inhibitor, is an emerging drug, which is being increasingly applied in oncology and solid organ transplantation. Oral ulcers are a frequent side effect associated with this immunosupressor. We report the case of a renal transplant recipient who developed disfiguring oral and perianal ulcers secondary to everolimus's toxicity. This is probably the first report of perianal involvement. Dermatologists need to be aware of the potential mucocutaneous adverse effects related to these new drugs that are becoming evermore common in our clinical practice.

Anal polyp caused by Schistosoma mansoni

We describe a schistosomal polyp in the anus of a 24-year-old patient, born in Viçosa, State of Minas Gerais, and living in Belo Horizonte, State of Minas Gerais. From 8 to 13 years of age, he swam in the rivers that bathe Viçosa. The histopathological examination has shown a lesion, lined by a keratinized squamous epithelium, ulcerated, with granulomas, centered or not by Schistosoma mansoni egg, laid, in loco, by the female present in the vascular lumen of a vein of the hemorrhoidal plexus. There was also a diffuse, nonspecific inflammation in the dermis. The patient was treated with praziquantel. Four months after the treatment, sigmoidoscopy showed a normal rectal mucosa, and negative oogram and stool tests. Ultrasound of abdomen was normal.

Infecciones graves del periné: unificación de conceptos / Perineal severe infections: concepts unification

Esta monografía se refiere a diferentes procesos que se caracterizan por una inflamación progresiva de la región perineal que llega a la necrosis de la piel, el tejido celular subcutáneo y ocasionalmente el músculo, generando una severa toxicidad sistémica. Es necesario agruparlos bajo la denominación de “infecciones graves del periné” teniendo en cuenta su forma similar de presentación, el diagnóstico precoz que merecen, y el tratamiento exhaustivo del que depende su curación. Existen factores predisponentes, como la diabetes mellitus, y otros desencadenantes, como los procedimientos invasivos locorregionales, que favorecen la aparición de esta afección. Las causas más frecuentes son infecciones anorrectales, genitourinarias y lesiones traumáticas. Casi todos los casos se caracterizan por presentar flora bacteriana mixta y sinérgica. En los cultivos se identifican organismos anaerobios y aerobios facultativos. El diagnóstico se basa en los hallazgos clínicos. La utilidad de las imágenes se limita al diagnóstico precoz de lesiones que potencialmente pueden dar lugar al surgimiento de esta entidad, y a la búsqueda de colecciones que han pasado desapercibidas. La bacteriología provee las bases para ejercer un programa de tratamiento de rutina. El tratamiento debe ser instaurado inmediatamente. La buena evolución de esta grave patología se basa en las medidas urgentes y generales de reanimación, compensación y sostén, antibióticoterapia adecuada, y con una cirugía que siempre debe ser precoz y agresiva. El impacto de la terapia coadyuvante con oxígeno hiperbárico en cuanto a mejoras en los resultados permanece en controversia. Con respecto a la cirugía reparadora, debe tenerse en cuenta que el realizar un debridamiento agresivo, conlleva acarrear con malos resultados estéticos y dificultad en la cicatrización del lecho quirúrgico...

This work talks about different processes that characterize by a progressive inflammation of the perineal region which includes skin, hypodermis and occasionally the muscle necrosis, generating a severe general toxicity. It is necessary to group them under the denomination of “serious infections of perineum” considering its similar form of presentation, the precocious diagnosis needed, and the exhaustive treatment that depends its treatment. There are many helping factors, such as diabetes mellitus, and other leading ones, like regional invasive procedures, which help to promote this affection. The most frequent causes are anorectal and genitourinary infections, and traumatic injuries. Almost all cases are characterized by displaying mixed and sinergical bacterial flora. Anaerobic and facultative aerobic organisms are identified in tissue cultures. The diagnosis is based on the clinical findings. The utility of images is limited to the precocious diagnosis of injuries that can give rise to the sprouting of this illness, and the search of unnoticed collections. Bacteriology provides the bases to start a program of routine treatment. Treatment must be restored immediately. The favorable evolution of this serious pathology is based on urgent and general measures of resuscitation, suitable antibiotic therapy, and surgery, that always must be precocious and aggressive. The impact of helping hyperbaric oxygen therapy as far as improvements in results remains in controversy. As far as repairing surgery, it must be consider that making an aggressive surgery entails to carry with bad aesthetic results and difficulties in the cicatrization of the surgical wound. This fact does not have to be more important than the initial therapeutic success, which will save of the patient's life. Without a suitable handling, the perineum severe infections present a terrible prognosis, with high mortality rate and anatomic and functional sequels that causes invalidity.

Diagnostic methods for prevention of anal cancer and characteristics of anal lesions caused by HPV in men with HIV/AIDS

Abnormalities found with anuscopy under colposcopic vision, anal cytology and anal biopsy were evaluated in 21 men with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) at the Federal University of Pernambuco Hospital in Brazil. Mean age was 38.4 ± 6.0 years, and mean time of HIV infection was 8.3 ± 5.1 years; 95.2 percent of the patients had been on highly active antiretroviral therapy (HAART) for an average of 6.6 ± 4.5 years. Mean CD4+ cell count was 482.2 ± 173.75 cells/mm³, and 80.9 percent presented a HIV viral load of < 5,000 copies/mL. Reported sexual preference was 52.4 percent homosexuals, 28.6 percent bisexuals, and 19.0 percentheterosexuals; 81 percent reported having had receptive anal intercourse and 61.9 percent reported more than 10 sexual partners of the same sex. Results of anuscopy under colposcopic vision revealed 17 (81.0 percent) low-grade lesions and/or condylomata or micropapillae and four (19.0 percent) high-grade lesions with or without condylomata. Among the 21 anal cytology examinations, seven (33.3 percent) revealed low-grade squamous intraepithelial lesions (LSIL); three (14.3 percent) presented atypical squamous cells of undetermined significance (ASCUS) and 11 (52.4 percent) were normal. Seventeen patients were submitted to anal biopsy with the following findings: three patients (17.6 percent) with normal epithelium, one (5.9 percent) with infection by HPV, three (17.6 percent) with condylomatas, two (11.8 percent) with AIN 1, four (23.6 percent) with AIN 2, three (17.6 percent) with AIN 3, and one (5.9 percent) with PAIN 2. Anuscopy under colposcopic vision was found to be useful for detecting anal lesions and for guiding anal biopsies. Anal cytology was less useful, as it underestimated the frequency of lesions.

Extramammary Paget's disease.

Two patients with extramammary Paget's disease are being reported. The first case was a 60-year-old male who presented with gradually progressive pruritic ulcerated lesion over perianal region not responding to various topical medications. Dermatological examination revealed a large erythematous sharply marginated scaly plaque in the perianal region extending into the anal canal, covered with grayish crusts and shallow erosions. Skin biopsy from the lesion was suggestive of Paget's disease. The second patient, a 60-year-old male, with a three year long history, presented with similar lesions and findings. Skin biopsy in this case was also consistent with Paget's disease. These two cases of extramammary Paget's disease involving the perianal region are being reported because of their rarity and also to stress the fact that a high degree of suspicion is needed for the diagnosis of this uncommon disease entity.

Liquen escleroso: a propósito de un caso / Lichen sclerosus: apropos of a case

Se presenta la evolución de un liquen escleroso extragenital en una paciente diabética, de 67 años, con discordancia inicial entre la clínica y la histopatología, el cual posteriormente se complicó con un carcinoma espinocelular vulvar. Se realiza una revisión del tema y de la conducta terapéutica, especialmente en mujeres.

A Case of Focal Acantholytic Dyskeratosis Occurring on both the Lip and the Anal Canal

Focal acantholytic dyskeratosis has a distinctive histological pattern that is associated with various clinical expressions. It rarely occurs on the lip or the perianal area. We report a patient with focal acantholytic dyskeratosis occurring on both the upper lip and the anal canal. Histopathologically, the lesions showed hyperkeratosis, suprabasilar clefting, epidermal acantholysis and dyskeratosis. This case represents the first report of a focal acantholytic dyskeratosis occurring on both the lip and the anal canal.

Histiocitose das células de Langerhans na regiäo anogenital / Langerhans cell histiocytosis in anogenital region

A Histiocitose das células de Langerhans (HCL) acometendo o trato genital tem uma incidência rara com apenas 48 casos relatados na literatura. Considerando somente as lesoes da regiao anogenital, esse número cai para dois casos descritos. Reportamos o 3º caso de HCL anogenital em uma paciente de 31 anos, branca, cuja comprovaçao diagnóstica foi feita através de microscopia eletrônica. O tratamento realizado foi quimioterapia sistêmica e excisao cirúrgica local.

Maladie de buschke-lowenstein ano-rectale [a'propos de 5 cas]

The authors report a series of 5 cases of Buschke Lowenstein's anorectal tumors. In one case the tumor degenerated. The treatment consists in a surgical exercise associated with an electro coagulation. Radiotherapy is indicated in one case of dysplasia and in the case of degeneracy. Evolution is good in the three cases seen in consultation with, in one single patient, five years' recoil. 20 cases are collected in medical literature till 1989 and 42 cases reported in English literature till 1994. These cases are comparatively studied with our series. Key words: Condyloma acuminatum, Buschke Lowenstein's anorectal disease. Excision, Electro coagulation Radiotherapy

Tuberculose ano-retal / Anorectal tuberculosis

Foram estudados 8 pacientes com tuberculose ano-retal, avaliando-se o quadro clinico, criterio de diagnostico, frequencia da tuberculose pulmonar associada, tipo macroscopico da lesao e tratamento clinico e cirurgico. Houve predominio do sexo masculino (3:1), e a idade esteve acima dos 38 anos na maioria dos pacientes com tuberculose anal, e foi de 33 e 38 anos na tuberculose retal. A dor ao evacuar foi o sintoma mais frequente na forma anal, e dor abdominal, nauseas, vomitos e emagrecimento predominaram na forma retal. Realizamos pesquisa BAAR no escarro (50 por cento), biopsia da lesao ano-retal (25 por cento), histopatologia do trajeto fistuloso ressecado (50 por cento), transito delgado (37,5 por cento), enema opaco (50 por cento), Mantoux (100 por cento), e raio X simples de torax (100 por cento), como criterios de diagnostico. A associacao com tuberculose pulmonar estava presente em 62,5 por cento dos casos. O exame microscopico, revelou 1 caso de tuberculose retal ulcerativa, e outro de ulcero-hiperplastica. Todos os casos de tuberculose anal foram do tipo ulcerativo. A cura foi observada em 100 por cento dos casos com o tratamento especifico. O tratamento cirurgico foi realizado em 4 pacientes, portadores de fistula anal.

Absceso intermuscular alto: consideraciones anatómicas, clínicas y patológicas / High intermuscular abscess: anatomic, clinical and pathological considerations

Analizamos el tema del absceso intermuscular alto anal desde el punto de vista anatómico, clínico y patológico. De nuestro análisis anatómico hemos concluido que es poco probable que el absceso en causa asiente en el espacio que le asignaron los autores que lo han descrito. De la misma manera planteamos otra teoría en torno a su localización anatómica. Desde el punto de vista clínico analizamos nuestra casuística de cuatro abscesos y de sus pautas diagnósticas y terapéuticas