[The consensus of the Portuguese Society of Andrology, Sexual Medicine and Reproduction on Male HPV: diagnosis]. / Consensos em HPV masculino da Sociedade Portuguesa de Andrologia, Medicina Sexual e Reprodução: diagnóstico.

HPV infection affects about 50% of sexually active individuals at least once in a lifetime. Diagnosis is made on careful inspection of the genital area and can be divided into benign lesions (genital warts or condyloma acuminatum) and pre-malignant lesions (intraepithelial neoplasia) that can lead to cancer (invasive neoplasia). Diagnostic recommendations are reviewed in Male, Female, Couple and in the immunocompromised host. Recent histological concepts are also discussed.

Extragenital Gonorrhoea in Men Who Have Sex with Men: A Retrospective Study in a STI Clinic in Lisbon, Portugal.

INTRODUCTION: Recent studies worldwide reveal a significant prevalence of extragenital infections by Neisseria gonorrhoeae among men who have sex with men. We aimed to analyse the frequency and characteristics of extragenital gonococcal infections diagnosed in men who have sex with men in a walk-in Sexually Transmitted Infection clinic in Lisbon, Portugal. MATERIAL AND METHODS: We conducted a cross-sectional, retrospective study of the anorectal and/or oropharyngeal Neisseria gonorrhoeae infections in men who have sex with men, diagnosed in our Sexually Transmitted Infection clinic between January 2014 and December 2016. RESULTS: We found extragenital infection in 87 cases of gonorrhoea identified in men who have sex with men in this period, including: 49 cases of anorectal disease, 9 of oropharyngeal disease, 13 cases of infection at both extragenital sites, and 16 of simultaneous extragenital and urogenital gonorrhoea. Patients' ages ranged from 17 to 64 years (median: 28 years). Forty-seven (54%) of the patients did not present with any extragenital symptoms. Thirty (35%) were human immunodeficiency virus-1-positive. DISCUSSION: Since most extragenital Neisseria gonorrhoeae infections are asymptomatic, they may be missed and go untreated unless actively investigated. Current international guidelines recommend the screening of gonorrhoea at extragenital sites in men who have sex with men because anorectal and oropharyngeal infections constitute a potential disease reservoir, and may facilitate transmission and/or acquisition of human immunodeficiency virus infection. CONCLUSION: Our results highlight the relevance of testing men who have sex with men for Neisseria gonorrhoeae at extragenital sites, regardless of the existence of local complaints. The implementation of adequate screening programmes in Portugal should be considered. We also reinforce the need to raise awareness in the population regarding the adoption of prophylactic measures against transmission of sexually transmitted infections during anal and/or oral sexual exposure.

Introdução: Estudos internacionais recentes revelam uma prevalência significativa de infeções extragenitais por Neisseria gonorrhoeae em homens que têm sexo com homens. Pretendemos analisar a frequência e caraterísticas das infeções gonocócicas extragenitais diagnosticadas em homens que têm sexo com homens numa consulta aberta de Infeções Sexualmente Transmissíveis em Lisboa, Portugal. Material e Métodos: Conduzimos um estudo observacional transversal, retrospetivo, das infeções anorrectais e/ou orofaríngeas por Neisseria gonorrhoeae em homens que têm sexo com homens, diagnosticadas na nossa consulta de Infeções Sexualmente Transmissíveis entre janeiro de 2014 e dezembro de 2016. Resultados: Detetámos infeção extragenital em 87 dos casos de gonorreia identificados em homens que têm sexo com homens no período analisado, incluindo: 49 casos de doença anorrectal, 9 de doença orofaríngea, 13 casos de infeção em ambas as localizações extragenitais, e 16 de gonorreia simultaneamente extragenital e urogenital. A idade dos doentes variou entre 17 e 64 anos (mediana: 28 anos). Quarenta e sete (54%) dos doentes não apresentavam qualquer sintoma extragenital. Trinta (35%) tinham também infeção pelo vírus da imunodeficiência humana-1. Discussão: Dado que a maioria das infeções extragenitais por Neisseria gonorrhoeae são assintomáticas, estas podem não ser diagnosticadas, e não tratadas, se não pesquisadas ativamente. Em várias normas de orientação clínica internacionais atuais é recomendado o rastreio da gonorreia em localizações extragenitais em homens que têm sexo com homens, visto que as infeções anorrectais e orofaríngeas constituem potenciais reservatórios da doença e podem facilitar a transmissão e/ou aquisição de infeção pelo vírus da imunodeficiência humana. Conclusão: Os nossos resultados apontam para a relevância de testar os homens que têm sexo com homens para a presença de Neisseria gonorrhoeae em localizações extragenitais, independentemente da existência de sintomas locais. A implementação de programas de rastreio adequados em Portugal deverá ser considerada. Relevamos também a necessidade de sensibilizar a população para a adoção de medidas profiláticas contra a transmissão de infeções sexualmente transmissíveis durante o contacto sexual anal e/ou oral.

Nodular mucinosis misdiagnosed as non-responsive secondary syphilis.

A previously healthy 24-year-old man presented with an erythematous, non-pruritic and painless papulonodular skin rash affecting the trunk, upper arms (excluding palms), neck, face, forehead and scalp. He had a penile ulcer for the past 2 weeks, almost healed at the time of observation. The patient tested positive for syphilis and HIV-1; he claimed being negative for HIV 6 months earlier. As the palms were not affected, we performed a skin biopsy for the differential diagnosis between secondary lues and acute HIV seroconversion reaction. Benzathine penicillin (2,400,000 units) was administrated and antiretroviral therapy started. Although the skin biopsy was compatible with secondary syphilis, there was no change in the skin rash 3 weeks after the first penicillin administration. Another 2 doses of penicillin were given but 4 weeks later the rash persisted. A second biopsy revealed a mucinous skin infiltration, compatible with nodular mucinosis.

Herpes hipertrófico perianal tratado eficazmente com imiquimod / Hypertrophic perianal herpes successfully treated with imiquimod

A infecção pelo vírus herpes simples tipo 2 (HSV-2) é frequente em pacientes infetados pelo vírus de imunodeficiência adquirida (VIH). Nestes casos, o herpes genital pode ter uma apresentação clínica atípica. As variantes hipertróficas e vegetantes são pouco habituais. Os autores relatam um caso de herpes hipertrófico perianal em paciente infetada pelo VIH, com resposta insatisfatória ao aciclovir e valaciclovir, tratado eficazmente com imiquimod tópico. O herpes genital hipertrófico é, frequentemente, refratário aos tratamentos antivirais. Na nossa experiência, o imiquimod é um tratamento eficaz, seguro e bem tolerado que deverá ser considerado na abordagem terapêutica destes pacientes.

Herpes simplex virus type 2 (HSV-2) infections are frequent in HIV (human immunodeficiency virus) infected patients. In those cases, genital herpes may have an atypical clinical presentation. Hypertrophic and vegetating variants are unusual. The authors describe a case of hypertrophic perianal herpes in an HIV patient with unsatisfactory response to acyclovir and valacyclovir, successfully treated with imiquimod. Hypertrophic genital herpes cases are frequently refractory to antiviral treatments. In our experience, imiquimod is an efficient, safe and well tolerated treatment that should be considered in therapeutic approach of these patients.

Hypertrophic perianal herpes successfully treated with imiquimod.

Herpes simplex virus type 2 (HSV-2) infections are frequent in HIV (human immunodeficiency virus) infected patients. In those cases, genital herpes may have an atypical clinical presentation. Hypertrophic and vegetating variants are unusual. The authors describe a case of hypertrophic perianal herpes in an HIV patient with unsatisfactory response to acyclovir and valacyclovir, successfully treated with imiquimod. Hypertrophic genital herpes cases are frequently refractory to antiviral treatments. In our experience, imiquimod is an efficient, safe and well tolerated treatment that should be considered in therapeutic approach of these patients.

Borderline CD30+ cutaneous lymphoproliferative disorder: report of a case with expression of cytotoxic markers and response to clarithromycin.

CD30+ cutaneous lymphoproliferative disorders (CLPDs) are usually characterized by a benign clinical course. The prognostic value of cytotoxic markers in these lymphomas has not been evaluated in large series. We describe a case of borderline CD30+ CLPD with cytotoxic phenotype, presenting in a 22-year-old male patient as an ulcer on the forearm. He reported having had similar ulcers on the buttock and thigh that spontaneously regressed over the course of 1 year. The lesion resolved with a single course of clarithromycin; a subsequent lesion, too, responded to clarithromycin, and no recurrences or systemic involvement have been documented in the 9-month follow-up. A conservative approach in the management of CD30+ CLPD is recommended. We believe that the anti-inflammatory and apoptotic effects of clarithromycin on T cells may have hastened the remission process.

[Churg-Strauss syndrome presenting with cutaneous vasculitis]. / Síndrome de Churg-Strauss - Vasculite cutânea como forma de apresentação clínica.

Churg-Strauss syndrome (CSS), also known as allergic granulomatous angiitis, is a rare disorder characterized by the presence of asthma, eosinophilia and small-to-medium sized vessels vasculitis. Vasculitis commonly affects lung, heart, skin and peripheral nerves. The authors report a case of a 47-year-old woman that was admitted with a 1-week history of painful purpuric lesions affecting extensor surfaces of lower extremities. She had a 7 years-long medical history of asthma, paranasal sinusitis and allergic rhinitis. Laboratorial tests revealed leucocytosis, peripheral blood eosinophilia and elevated inflammatory parameters. Antineutrophil cytoplasmic antibodies were negative. Skin biopsy was consistent with necrotizing vasculitis with perivascular eosinophil-rich infiltrate. Electromyogram and nerve conduction studies showed asymmetrical peripheral polyneuropathy. Churg-Strauss syndrome diagnosis was supported by clinical and histopathological findings. High-dose oral steroid therapy led to a dramatic clinical improvement. Skin manifestations can be the presenting feature of Churg-Strauss syndrome. Early recognition is essential for appropriate treatment and prevention of irreversible organ damage.

Treatment of Vascular Lesions of the Tongue with Nd:YAG Laser.

The treatment of vascular lesions of the tongue is a very challenging procedure since the maintenance of the lingual tissue is of critical importance. Numerous treatment options have been described in literature but the Nd:YAG Laser appears to be one of the safest therapeutic options. We described a successful treatment of vascular lesions of the tongue with an excellent clinical result after only one treatment session with the Nd:YAG laser, with conservation of the lingual tissue and its functionality.

Annular lichen planus in association with Crohn disease.

BACKGROUND: Lichen planus is an idiopathic inflammatory disease of the skin and mucous membranes. Although the etiology is not established, it has been associated with autoimmune diseases, viral infections, drugs and dental restoration materials. However, the association with inflammatory bowel disease has been very rarely reported in the literature. CASE REPORT: A 19-year-old female patient presented with annular lesions on her upper body and limbs, with a sharply defined border and non-atrophic skin in the center. The lesions were hyperpigmented and had been stable for over one year. The histopathology confirmed the diagnosis of annular lichen planus. She had weight loss, occasional diarrhea, and a severe anemia. The investigation of these symptoms led to the diagnosis of Crohn disease and a sickle cell trait. Therapy with systemic corticosteroids and mesalazine controlled the intestinal disease, with concomitant improvement of the skin lesions. CONCLUSIONS: As lichen planus can be associated with other immunological disorders, the association with inflammatory bowel disease should be considered in the evaluation of the patient.

Localized abdominal idiopathic lipodystrophy.

Localized loss of subcutaneous tissue can occur after panniculitis, injections of corticosteroids and other drugs, or associated with infectious, autoimmune or neurologic diseases. The "idiopathic lipoatrophies" are a group of poorly characterized diseases, with focal disappearance of subcutaneous fat, and usually the thighs, abdomen or the ankles are affected. Three subtypes have been described based on clinical presentation: lipoatrophia semicircularis, annular lipoatrophy of the ankles and centrifugal lipodystrophy. We describe a 52-year-old female patient who developed a localized atrophy of the abdominal areas over a period of 3 months without any inflammatory signs over the evolution of the disease. The patient denied any previous local trauma or medication of any type. The atrophy stabilized, showing no progression over the last 6 years. The histopathological examination was normal except for the absence of subcutaneous fat, although the biopsy was taken down to the fascia. There was no clinical or serologic evidence of autoimmune diseases and laboratory testing for Borrelia burgdorferi infection was negative. Other causes of localized lipoatrophies were excluded and the final diagnosis was localized idiopathic lipodystrophy. Our patient is the second report on an abdominal lipodystrophy, with no previous inflammatory signs, absence of subcutaneous fat and no associated pathogenic factor. There is no established treatment for idiopathic lipodystrophy, and the lesions do not tend to resolve spontaneously.

[Acute generalized exanthematous pustulosis associated with diltiazem]. / Pustulose generalizada exantemática aguda associada ao diltiazem.

Acute generalized exanthematous pustulosis (AGEP) usually presents with the acute appearance of oedematous and erythematous lesions, on which multiple sterile pustules appear, associated with fever. Almost 90% of cases are associated with drugs, with antibiotics (penicillins and macrolides) being the most frequent causative agents. We describe a 36-year-old female patient, which started diltiazem 120mg/day for hypertension. After 6 days of therapy, multiple erythematous and oedematous lesions appeared, with associated multiple small non-follicular pustules. Oral corticosteroids were started, with progressive and complete improvement. Patch-tests were performed, which revealed positivity for diltiazem. Although a rare entity, AGEP must be considered in cases of acute eruptions with disseminated pustules and fever. The use of patch tests in this disease may be useful as positive reactions are frequent.