Comparison of PCR-based methods for the diagnosis of cutaneous leishmaniasis in two different epidemiological scenarios: Spain and Morocco.

BACKGROUND: Cutaneous leishmaniasis (CL) is a disfiguring and stigmatising disease occurring in more than 70 countries across the world including Spain and Morocco. The use of sensitive tests that can differentiate Leishmania species is advised. OBJECTIVE: To evaluate the influence of the epidemiological scenario on the reliability of the PCR techniques and contribute to the selection of the most efficient one for CL diagnosis. METHODS: The sensitivities of parasitological methods and four PCRs were compared in cutaneous samples from 77 patients from Spanish (PSH) and Moroccan hospitals (PMH). Exudates and fresh or paraffin-embedded tissue biopsies were used. RESULTS: None of the PCRs used in this study allowed the diagnosis of all CL cases, showing also some drawbacks. Lmj4/Uni21-PCR displayed the best sensitivity with PMH, but it did not provide positive results in PSH with CL confirmed by other PCRs. Conversely, JW13/JW14-PCR and L. infantum-PCR-ELISA displayed good sensitivities with PSH that were not achieved with PMH. Nested-ITS-1-PCR did not show enough sensitivity with paraffin-embedded tissue biopsies. False-negative results were obtained in 19% of PSH due to unspecific hybridizations of ITS-1 primers with human chromosome1. CONCLUSIONS: PCR should be routinely used in patients with cutaneous lesions compatible with CL and furthermore, the combination of two PCR techniques is advisable. The selection of these PCRs will be influenced by the epidemiological scenario: In areas where L. infantum is endemic, the use of the PCR-ELISA joint with JW13/JW14-PCR seems an appropriate choice, whereas in areas such as Morocco, Lmj4/Uni21 and ITS-1 provide satisfactory results.

Cutaneous leishmaniasis by Leishmania infantum: behind granulomatous lesions of unknown aetiology.

BACKGROUND: Cutaneous leishmaniasis (CL) is underestimated in Spain as in other European countries due to the polymorphism of its clinical manifestations and histopathological features discouraging doctors from suspecting leishmaniasis. Mucosal manifestations (ML) are misdiagnosed due to the fact that they often mimic cancer. OBJECTIVES: Given that leishmaniasis may be masked as different granulomatous diseases in Leishmania infantum endemic areas, the aim of this study was to verify this misdiagnosing and contributes to the improvement of CL/ML diagnosis. METHODS: A retrospective study involving formalin-fixed paraffin-embedded tissue biopsies with histopathological features of granulomatous lesions of unknown origin (GLUO) detected in 17 patients. This study included 13 patients with CL that was used as positive controls, nine patients with other confirmed diseases used as negative controls and seven patients with histological features suggestive of CL or ML without confirmation. Molecular analysis was blindly performed using two different PCR techniques. RESULTS: The PCR detected 15 CL cases in which the diagnosis was neither clinically nor histologically suspected. Leishmaniasis was confirmed in seven suspected patients in whom the classical techniques failed to detect the parasite. L. infantum was identified in all cases. A systematic review of CL cases in GLUO patients from European countries identified 45 reported cases. CONCLUSIONS: In L. infantum endemic areas, a high percentage of GLUO are due to Leishmania infection. The main consequences are delayed diagnosis and underestimation of the real incidence. PCR performed on paraffin-embedded tissue proved to be a reliable tool for diagnosis of CL/ML and must be performed routinely in any granulomatous dermatitis, even when the morphological features are no stereotypical of leishmaniasis.

Intralymphatic Histiocytosis: A Report of 2 Cases. / Histiocitosis intralinfática, a propósito de 2 casos.

Intralymphatic histiocytosis is a benign condition characterized by poorly defined erythematous plaques (sometimes forming a reticular pattern) as well as the presence of nodules and vesicles. Its etiology and pathogenesis appear to be related to chronic inflammation in the affected area, prior surgery, or systemic disease, particularly rheumatoid arthritis. We report on 2 new cases, both associated with joint surgery in the affected area and osteoarticular disease (primary synovial osteochondromatosis and rheumatoid arthritis). This is a chronic disease and there is no specific treatment. Different treatment options were chosen in the 2 cases described. A spectacular response to treatment with oral pentoxifylline and topical tacrolimus was observed in 1 of the patients.

[Anti-fungal resistant hypopigmented macules in an adolescent]. / Máculas hipopigmentadas en un adolescente resistentes a tratamiento antifúngico.

Progressive macular hypomelanosis of the trunk is a disease of unknown origin that often goes unrecognized in the clinical setting. We present an adolescent with this condition initially diagnosed as tinea versicolor. She was asymptomatic, with hypopigmented macules located on the trunk and with no previous history of inflammation, infection or injury. Progressive macular hypomelanosis is a common disorder that has frequently been misdiagnosed, probably because it is often considered a post-inflammatory hypopigmentation or pityriasis versicolor.

Máculas hipopigmentadas en un adolescente resistentes a tratamiento antifúngico / Anti-fungal resistant hypopigmented macules in an adolescent

La hipomelanosis macular progresiva del tronco es una entidad de etiología desconocida, que a menudo pasa desapercibida en el entorno clínico. Presentamos el caso de un adolescente con esta enfermedad inicialmente diagnosticada como pitiriasis versicolor. Las lesiones estaban formadas por máculas, hipopigmentadas, asintomáticas y localizadas en el tronco, sin historia previa de inflamación, infección o lesión. La hipomelanosis macular progresiva es un trastorno común con frecuencia mal diagnosticado, probablemente debido a que a menudo se considera una hipopigmentación post-inflamatoria o una pitiriasis versicolor (AU)

Progressive macular hypomelanosis of the trunk is a disease of unknown origin that often goes unrecognized in the clinical setting. We present an adolescent with this condition initially diagnosed as tinea versicolor. She was asymptomatic, with hypopigmented macules located on the trunk and with no previous history of inflammation, infection or injury. Progressive macular hypomelanosis is a common disorder that has frequently been misdiagnosed, probably because it is often considered a post-inflammatory hypopigmentation or pityriasis versicolor (AU)

Granulomatous cheilitis: a report of 6 cases and a review of the literature.

INTRODUCTION: Granulomatous cheilitis (Miescher cheilitis), a condition characterized by recurrent swelling of the lips, is the most common monosymptomatic form of the Melkersson-Rosenthal syndrome. The aim of this study was to study the characteristics of patients diagnosed with granulomatous cheilitis at the dermatology department of our hospital over a period of 17 years. MATERIAL AND METHODS: We performed a descriptive study of patients diagnosed with granulomatous cheilitis at our hospital between January 1993 and January 2010. RESULTS: The condition was diagnosed in 6 patients (4 women and 2 men), with a mean age of 49 years at the time of diagnosis. All the patients had recurrent swelling of the upper lip and 2 also had swelling in other parts of the face. The mean time from the onset of symptoms to the initial visit was approximately 16 months. There were no cases of facial palsy, and just 1 patient had a fissured tongue. None of the patients developed Crohn disease or any other granulomatous disorders during follow-up. CONCLUSIONS: Granulomatous cheilitis is a rare disease. None of the patients in our series had gastrointestinal or neurologic symptoms. Accordingly, we believe that granulomatous cheilitis is an independent orofacial granulomatous disease which most often presents without accompanying signs or symptoms.

Morfeas en la infancia: estudio retrospectivo / Morphea in childhood: a retrospective study

La morfea es una enfermedad infrecuente, cuya prevalencia no está bien establecida. Nuestro objetivo es determinar las características de los pacientes pediátricos diagnosticados de morfea en nuestro servicio. Método: Estudio observacional retrospectivo. Registro de los pacientes pediátricos con diagnóstico clínico e histológico de morfea desde enero de1996 hasta abril de 2010.Resultados: Trece pacientes en edad pediátrica fueron diagnosticados clínica e histológicamente de morfea, 9 mujeres y 4 hombres, con una media de edad de 12,6 años. El tiempo transcurrido desde el primer signo de morfea hasta el diagnóstico fue de 5,69 meses. La forma clínica más frecuente fue la morfea en placas (61,54%), seguida de generalizada (23,07%) y la lineal (15,38%). Fueron hallados ANA+ en 38,46% y eosinofilia en 23,07%de los pacientes. Se observaron manifestaciones extracutáneas en cuatro pacientes (30,77%); tres casos (23,07%) se acompañaron de clínica neurológica, y dos de enfermedades autoinmunes (15,38%). La evolución de las lesiones fue hacia la resolución en todos los casos, excepto en 3 pacientes (23,08%) que presentaron persistencia de las mismas con episodios de exacerbación. Discusión y conclusiones: La morfea en la infancia no siempre presenta una evolución benigna hacia la resolución completa. La mayoría de casos presentan una afectación leve y autolimitada, sin embargo este trastorno puede causar una discapacidad funcional permanente y afectación extracutánea (AU)

Morphea is an uncommon disease, whose prevalence is not well established. The aim of our studty was to determine the clinical features of morpheain pediatric patients diagnosed in our department. Methods: We retrospectively analized pediatric patients with clinical and histological diagnosis of morphea from Jannuary 1996 to April 2010. Results: Thirteen pediatric patients were diagnosed clinically and histologically of morphea, 9 women and 4 men. The mean age was 12,6 years. The time from the first sign of morphea to diagnosis was 5,69 months. The most frequent clinical presentation was plaque morphea (61,54%), followed by generalized (23,07%) and linear (15,38%). ANA were found in 38,46% and eosinophilia in 23,07% of patients. Extracutaneous manifestations were observed in four patients (30,77%); three cases (23,07%) were accompanied by neurological symptoms, and two of autoimmune diseases(15,38%). The outcome was good except in 3 patients (23,08%) who presented persistence of the disease with episodes of exacerbation. Conclusions: Morphea in childhood does not always have a benign course to complete resolution. Most patients have a mild and self-limited outcome, but this disorder can cause permanent dissability and non cutaneous manifestations (AU)

[Referrals to dermatology: proportion of banal disorders]. / Demanda derivada a Dermatología: peso de la patología banal.

BACKGROUND AND OBJECTIVE: Skin diseases account for a large number of consultations in primary care. The objective of this study was to determine the characteristics and cost of referrals from primary care to a dermatology clinic. MATERIAL AND METHODS: Descriptive cross-sectional study of referrals from a primary care health center to a dermatology clinic. The dermatology clinic was situated in the same health center and was attended by a dermatologist from Complejo Hospitalario Universitario in Albacete, Spain. The study was performed on 10 days selected at random between April 21, 2009, and June 26, 2009. The data gathered included age, sex, use of cryotherapy, and diagnostic group. Patients were divided into 4 diagnostic groups: A) benign degenerative disease or trivial disorders whose treatment may not merit involvement of the national health service, B) diseases resolved with a single dermatology consultation at the health center, C) diseases requiring evaluation in hospital-based dermatology outpatients, and D) diseases referred for surgical treatment. RESULTS: Data were gathered on 257 patients with a mean age was 41.18 years and there was a slight female predominance. The majority of patients were in diagnostic group B (53.7%), followed by groups A (19.1%), C (19.1%), and D (8.2%). The total estimated cost of these 257 visits was €29 750.32, of which €5672.24 was for trivial disorders. CONCLUSIONS: The current high prevalence of trivial disorders in the caseload of dermatology clinics by trivial disorders makes it necessary to control referrals from primary care more strictly.

[Dermatology consultations in an emergency department prior to establishment of emergency dermatology cover]. / Consultas dermatológicas en el Servicio de Urgencias: situación previa a la instauración de guardias de la especialidad.

BACKGROUND AND OBJECTIVE: an increasing number of patients seek emergency treatment for dermatologic complaints. The aim of this study was to assess the characteristics of skin complaints seen in an emergency department prior to establishment of specialist dermatology cover. MATERIALS AND METHODS: a retrospective, descriptive study was undertaken using data on urgent dermatology cases seen by nonspecialist physicians in the emergency department of Hospital General Universitario de Albacete, Spain, in 2008. RESULTS: a total of 3662 patients with skin diseases were seen (2.59% of all emergency cases; approximately 10 patients per day). The mean age was 27.73 years and there was a slight predominance of female patients. Children and adolescents accounted for 5.85% of cases. A total of 96 different conditions were diagnosed and 84% of cases corresponded to one of 21 different diagnostic entities, urticaria being the most frequent (19.27%). The 96 diagnoses were grouped into 16 categories to facilitate analysis. According to this classification, most patients had infectious diseases (47.49%), followed by urticaria and angioedema (20.13%), "nonspecific diagnosis" (11.93%), and "descriptive diagnosis" (6.49%). In 4.8% of cases, the patient was admitted, most frequently for cellulitis. CONCLUSIONS: in nonspecialist emergency services, the number of different diagnoses is small in relation to the number of patients seen and the proportion of nonspecific and descriptive diagnoses is relatively large. In our opinion, an on-call dermatologist should be made available within emergency departments in order to offer a higher quality of care to patients with skin conditions.

Consultas dermatológicas en el Servicio de Urgencias: situación previa a la instauración de guardias de la especialidad / Dermatology Consultations in an Emergency Department Prior to Establishment of Emergency Dermatology Cover

Introducción: los pacientes que solicitan atención urgente por problemas dermatológicos suponen una demanda asistencial creciente y numerosa. El objetivo de nuestro trabajo fue evaluar las características de la patología dermatológica en el Servicio de Urgencias antes de la implantación de las guardias de la especialidad. Material y métodos: estudio descriptivo y retrospectivo que recoge los datos referidos a la patología dermatológica urgente atendida, por médicos no especialistas, en el Servicio de Urgencias del Hospital General Universitario de Albacete durante el año 2008. Resultados: se atendió a un total de 3.662 pacientes con enfermedades dermatológicas (2,59% de urgencias dermatológicas, 10 pacientes/día). La edad media fue de 27,73 años, con un ligero predominio femenino. La población pediátrica supuso el 44,12%. Fueron diagnosticados 96 procesos diferentes, correspondiendo un 84% de toda la patología atendida a 21 entidades diagnósticas, siendo el diagnóstico más frecuente el de urticaria (19,27%). Los 96 procesos diagnósticos se agruparon en 15 patologías para su análisis, destacando en primer lugar la patología infecciosa (47,49%), seguida de urticaria y angioedema (20,13%), “diagnóstico inespecífico” (11,93%) y “diagnóstico descriptivo” (6,49%). Se realizaron 4,8% de ingresos, siendo la celulitis la causa más frecuente. Conclusiones: el número de diagnósticos diferentes se reduce en las consultas de urgencias generales, aumentando los diagnósticos inespecíficos y descriptivos. Consideramos necesaria la presencia de un dermatólogo de guardia para intentar ofrecer mayor calidad asistencial al paciente dermatológico (AU)

Background and objective: an increasing number of patients seek emergency treatment for dermatologic complaints. The aim of this study was to assess the characteristics of skin complaints seen in an emergency department prior to establishment of specialist dermatology cover. Materials and methods: a retrospective, descriptive study was undertaken using data on urgent dermatology cases seen by non specialist physicians in the emergency department of Hospital General Universitario de Albacete, Spain, in 2008. Results: atotal of 3662 patients with skin diseases were seen (2.59% of all emergency cases; approximately 10 patients per day). The mean age was 27.73 years and there was a slight predominance of female patients. Children and adolescents accounted for 5.85% of cases. A total of 96 different conditions were diagnosed and 84% of cases corresponded to one of 21 different diagnostic entities, urticaria being the most frequent (19.27%). The 96 diagnoses were grouped into 16 categories to facilitate analysis. According to this classification, most patients had infectious diseases (47.49%), followed by urticaria and angioedema (20.13%), “nonspecific diagnosis” (11.93%), and “descriptive diagnosis” (6.49%). In 4.8% of cases, the patient was admitted, most frequently for cellulitis. Conclusions: in nonspecialist emergency services, the number of different diagnoses is small in relation to the number of patients seen and the proportion of nonspecific and descriptive diagnoses is relatively large. In our opinion, an on-call dermatologist should be made available within emergency departments in order to offer a higher quality of care to patients with skin conditions (AU)