Dermatobia Hominis Infestation Misdiagnosed as Abscesses in a Traveler to Spain.

Dear Editor, A 29-year-old woman presented with abscesses on her buttock and leg attributed to flea bites inflicted 5 days earlier on return to Spain after 2 months in Guinea-Bissau. Ciprofloxacin was ineffective after 7 days, and she was referred for dermatologic evaluation. Examination revealed 4 round, indurated, erythematous-violet furunculoid lesions with a 1.5-2 mm central orifice draining serous material. She reported seeing larvae exiting a lesion, and we extracted several more (Figure 1). Parasitology identified Dermatobia (D.) hominis (Figure 2). Biopsy revealed intense dermal eosinophilic inflammatory infiltrate with a deep cystic appearance, surrounded by acute inflammatory infiltrate and necrotic material. Dermoscopy identified a foramen surrounded by dilated blood vessels and desquamation. A yellowish structure with a luminescent central ring was noted. Ultrasonography identified oval, hypoechoic, and hypovascular structures with inner echoic lines corresponding to cavities with debris and/or larval remains. Larvae were extracted before ultrasonography (Figure 1, b). Recommended treatment included topical antiseptic, occlusion of the infected area with paraffin, and 1% topical ivermectin; treatment resulted in incomplete resolution after 7 days. Furunculoid myiasis is more common in developing countries (1). Cases in Spain are usually imported, since the flies that produce this type of myiasis are not found locally. The species most frequently involved are D. hominis from Central and South America (botfly) and Cordylobia anthropophaga from the sub-Saharan region (tumbu fly) (2). We believe this was the first case in Spain imported from Guinea-Bissau. Several cases have been reported in Spain. Marco de Lucas et al. (3) reported a case in a Colombian male emigrant with multiple subependymal and intraventricular lesions, concentric blooming artifacts, and moderate hydrocephalus due to intracerebral myiasis. Another case was described by Arocha et al. (4). Central European countries continue to report new cases of imported furunculoid myiasis (5). D. hominis is a fly of the Oestridae family, approximately 1.5 cm long, yellowish-white in color, with a plumose edge (6). Larvae induce erythematous papules that sometimes ulcerate and resemble oils or large pustules, with a central orifice of about 1 mm, representing the larval respiratory pore. The lesions are usually painful (especially when larvae are still present) and pruritic, and produce sensations of movement under the skin. Lesions are located predominantly in exposed areas (7) and areas of contact with clothing and footwear, such as feet, buttocks, and external genitalia. Histopathology is not necessary for diagnosis, but usually reveals intense inflammatory infiltrate with abundant eosinophils surrounding larvae. (2) In our patient, ultrasound confirmed absence of living larvae within the cavity. D. hominis larvae show spontaneous movement in positive lesions and can be detected with ultrasound. Lesions in the hypodermis and dermis showed increased echogenicity of surrounding tissue, probably due to edema and inflammation (8). Diagnosis is established by comparing the lesion appearance with images of boils, abscesses, and inclusion of foreign body reaction cysts. Based on failed antibiotic therapy and travel to an endemic zone, myiasis should be considered in the differential diagnosis. Treatment consists of larval extraction through the respiratory orifice using pressure or a fine forceps or punch (9). Topical or oral ivermectin (10) can shorten the time to larval elimination. Physicians should be aware of this condition when travelers from endemic regions present with furuncular lesions, especially if movement is felt within the lesions or if lesions fail to heal. Myiasis is easily diagnosed based on clinical suspicion and epidemiological history, and is simple to treat.

Interleukin-2 and other cytokines in candidiasis: expression, clinical significance, and future therapeutic targets.

Susceptibility to Candida spp. infection is largely determined by the status of host immunity, whether immunocompromised/immunodeficient or immunocompetent. Interleukin-2 (IL-2), a potent lymphoid cell growth factor, is a four-α-helix bundle cytokine induced by activated T cells with two important roles: the activation and maintenance of immune responses, and lymphocyte production and differentiation. We reviewed the roles of cytokines as immune stimulators and suppressors of Candida spp. infections as an update on this continuously evolving field. We performed a comprehensive search of the Cochrane Central Register of Controlled Trials, Medline (PubMed), and Embase databases for articles published from March 2010 to March 2016 using the following search terms: interleukins, interleukin-2, Candida spp., and immunosuppression. Data from our own studies were also reviewed. Here, we provide an overview focusing on the ability of IL-2 to induce a large panel of trafficking receptors in skin inflammation and control T helper (Th)2 cytokine production in response to contact with Candida spp. Immunocompromised patients have reduced capacity to secrete Th1-related cytokines such as IL-2. The ability to secrete the Th1-related cytokine IL-2 is low in immunocompromised patients. This prevents an efficient Th1 immune response to Candida spp. antigens, making immunocompromised patients more susceptible to candidal infections.

Identification of Mycobacterium leprae and Mycobacterium lepromatosis in Formalin-Fixed and Paraffin-Embedded Skin Samples from Mexico

BACKGROUND: The causative agents of leprosy are the well-known Mycobacterium leprae and the newly discovered Mycobacterium lepromatosis. This agent was found in 2008, and it was found to be the cause of diffuse lepromatous leprosy in two Mexican patients. OBJECTIVE: The objective of this work was to determine if M. leprae and M. lepromatosis were present in formalin-fixed and paraffin-embedded skin samples from cases from different regions in Mexico. METHODS: A total of 41 skin samples were obtained from 11 states of Mexico. All patients' samples were diagnosed by clinical and histopathological analyses. Total DNA was isolated using a Qiagen-DNeasy blood and tissue kit and molecular identification was achieved by two semi-nested polymerase chain reactions. RESULTS: The 41 patient included 33 samples from men and 8 samples from women; 29 samples were polymerase chain reaction (PCR)-positive to Mycobacterium and 12 samples were PCR-negative. From those 29 samples, 13 were PCR-positive to M. leprae, 8 to M. lepromatosis and 8 were positive to both species. The histopathological diagnosis included; Nodular lepromatous leprosy (NLL); Diffuse lepromatous leprosy (DLL); and Borderline leprosy (BL). The 29 PCR-positive samples were classified as follow: 14 NLL, 4 DLL, and 11 BL. In the 12 samples negative to Mycobacterium, 7 showed the NLL, 2 DLL and 3 BL. CONCLUSION: These findings add evidence to the M. leprae and M. lepromatous distribution, clinical forms and participation of dual infections in Mexico.

Advances in Immunotherapy for Melanoma: A Comprehensive Review.

Melanomas are tumors originating from melanocytes and tend to show early metastasis secondary to the loss of cellular adhesion in the primary tumor, resulting in high mortality rates. Cancer-specific active immunotherapy is an experimental form of treatment that stimulates the immune system to recognize antigens on the surface of cancer cells. Current experimental approaches in immunotherapy include vaccines, biochemotherapy, and the transfer of adoptive T cells and dendritic cells. Several types of vaccines, including peptide, viral, and dendritic cell vaccines, are currently under investigation for the treatment of melanoma. These treatments have the same goal as drugs that are already used to stimulate the proliferation of T lymphocytes in order to destroy tumor cells; however, immunotherapies aim to selectively attack the tumor cells of each patient. In this comprehensive review, we describe recent advancements in the development of immunotherapies for melanoma, with a specific focus on the identification of neoantigens for the prediction of their elicited immune responses. This review is expected to provide important insights into the future of immunotherapy for melanoma.

Activation and IL-1β secretion of human peripheral phagocytes infected with Actinomadura madurae, Nocardia asteroides and Candida albicans

Objective To evaluate the ability of Actinomadura madurae (A. madurae) and Nocardia asteroides (N. asteroides), using Candida albicans (C. albicans) as prototypic control, to elicit the activation and IL-1β secretion of blood phagocytic cells from healthy donors. Methods Microscopic evaluation of phagocytosis/activation, cell viability and spectrophotometric quantitation of endocytosis/activation, were assessed by using formazan blue test in human blood phagocytes infected with C. albicans, A. madurae or N. asteroides treated with either normal human serum (NHS) or with decomplemented NHS. Interlukin-1β from culture supernatants of infected polymorphonuclear was tested by ELISA kit assay. Results Microscopic assay showed that phagocytosis and activation of adherent mononuclear phagocytes were greater with C. albicans followed by A. madurae and then by N. asteroides. Spectrophotometric assay in polymorphonuclear phagocytes infected with NHS-treated pathogens indicated that activation was similarly higher by C. albicans and A. madurae and lower by N. asteroides. Kinetic assays in infected polymorphonuclear cells showed that viability was decreased by C. albicans and N. asteroides or unaffected with A. madurae. Levels of IL-1β at 8 h of incubation were higher with C. albicans followed by A. madurae whereas lower levels were found with N. asteroides. Conclusions The extent of cell-viability and activation as well IL-1β secretion may be related with the virulence of C. albicans and N. asteroides and other parameters remain to be explored for assessing the virulence of A. madurae.

Activation and IL-1β secretion of human peripheral phagocytes infected with Actinomadura madurae, Nocardia asteroides and Candida albicans

OBJECTIVE@#To evaluate the ability of Actinomadura madurae (A. madurae) and Nocardia asteroides (N. asteroides), using Candida albicans (C. albicans) as prototypic control, to elicit the activation and IL-1β secretion of blood phagocytic cells from healthy donors.@*METHODS@#Microscopic evaluation of phagocytosis/activation, cell viability and spectrophotometric quantitation of endocytosis/activation, were assessed by using formazan blue test in human blood phagocytes infected with C. albicans, A. madurae or N. asteroides treated with either normal human serum (NHS) or with decomplemented NHS. Interlukin-1β from culture supernatants of infected polymorphonuclear was tested by ELISA kit assay.@*RESULTS@#Microscopic assay showed that phagocytosis and activation of adherent mononuclear phagocytes were greater with C. albicans followed by A. madurae and then by N. asteroides. Spectrophotometric assay in polymorphonuclear phagocytes infected with NHS-treated pathogens indicated that activation was similarly higher by C. albicans and A. madurae and lower by N. asteroides. Kinetic assays in infected polymorphonuclear cells showed that viability was decreased by C. albicans and N. asteroides or unaffected with A. madurae. Levels of IL-1β at 8 h of incubation were higher with C. albicans followed by A. madurae whereas lower levels were found with N. asteroides.@*CONCLUSIONS@#The extent of cell-viability and activation as well IL-1β secretion may be related with the virulence of C. albicans and N. asteroides and other parameters remain to be explored for assessing the virulence of A. madurae.

[Dynamic hip screw vs. percutaneous compression plate for trochanteric fractures]. / Fracturas pertrocantéricas en adultos mayores tratados mediante el tornillo dinámico de cadera vs placa de compresión percutánea.

OBJECTIVE: To compare functional results, hemorrhage, wound infection, post-operative complications and implant stability in 31A1 and 31A2 fractures treated with percutaneous compression plate or dynamic hip screw. MATERIAL AND METHODS: We made a cuasi-experimental, longitudinal, prospective and comparative study in a period from December 2004 to February 2005. STATISTICAL ANALYSIS: System SPSS version 11.0, with t Student, Xi square and U Mann-Whitney, with alpha 0.05. RESULTS: We included 26 patients with AO 31A1 and 31A2 fractures, 13 treated with percutaneous compression plate and 13 with dynamic hip screw. We did not found significant statistical difference in post-operative hospital stay; wound length, post-operative complications and consolidation time. There were no infection or other wound complications in either group. Time of surgery and hemorrhage were better in the percutaneous compression plate group (p < or = 0.05). CONCLUSIONS: Percutaneous compression plate offers similar functional results compared to the dynamic hip screw, with advantages in hemorrhage during surgery and after surgery, less surgery time, with less need of transfusions post-operatively.

Micosis superficiales en pacientes oncológicos. Estudio en 98 pacientes / Superficial mycosis in oncologic patients. A study in 98 patients

Introducción y objetivo: La frecuencia de infecciones bacterianas, virales y fúngicas es alta en los pacientes inmunosuprimidos. Las micosis superficiales pueden condicionar elevada morbi-mortalidad en los pacientes oncológicos, principalmente bajo inmunosupresión. El objetivo de este trabajo es de conocer la frecuencia y etiología de las infecciones micóticas superficiales en pacientes oncológicos hospitalizados con o sin inmunosupresión. Material y métodos: Estudio prospectivo, descriptivo y transversal de las micosis superficiales en 98 pacientes oncológicos hospitalizados en el Instituto Nacional de Cancerología. Resultados: Entre 98 pacientes, el 31,6% de los pacientes estudiados presentaron por lo menos alguna micosis superficial. Las más frecuentemente encontradas fueron las onicomicosis (58%), pie de atleta (38,7%) e intertrigos micóticos inguinales (9,6%). Fue mayor la frecuencia y extensión de las micosis superficiales en los pacientes inmunosuprimidos (41,1%) que en los no inmunosuprimidos (29,6%). Los agentes causales más frecuentes fueron T. rubrum (36,3%) y levaduras del género Candida (11,2%). Conclusiones: Las infecciones fúngicas superficiales son frecuentes en los pacientes oncológicos hospitalizados y son más graves en los inmunosuprimidos. La más frecuente fue la onicomicosis y el agente causal más comun fue T. rubrum. No hubo infecciones sistémicas secundarias a micosis superficiales

Background and objective: Bacterial, viral and mycotic infections are highly frequent in immunocompromised patients. Superficial mycosis can increase morbidity and mortality in oncologic patients, particularly in the immunosupressed. The objective of this work is to know the frequency and etiologic agents of superficial mycotic infections in a population of immunosupressed and not immunosupressed hospitalized oncologic patients. Material and methods: Superficial mycotic infections in ninety eight oncologic hospitalized patients in the “Instituto Nacional de Cancerología” were studied. Results: At least one type of superficial mycosis was present in 31.6% of 98 patients. Onychomycosis (58%), athlete´s foot (38.7%), candidiasis and tinea cruris (9.6%) were the most frequent types found. Frequency was higher in immunosupressed hosts (41.1%) than in the not immunosupressed (29.6%). The most common causal agents were T. rubrum (36.3%) and Candida sp (11.2%). Conclusions: Superficial mycosis are frequent in hospitalized oncologic patients, predominantly in immunosupressed hosts in which they tend to be more severe. Onychomycosis was the most common infection and, as usual, we also corroborate the higher incicdence of T. rubrum. No systemic infections due to superficial mycosis were found

HLA-DR association with the genetic susceptibility to develop ashy dermatosis in Mexican Mestizo patients.

BACKGROUND: Ashy dermatosis, also known as erythema dyschromicum perstans, is an acquired benign disease, characterized by blue-gray pigment patches with erythematous borders. The cause is still unclear, but probably has an immunologic basis. OBJECTIVE: The aim of this study was to determine gene frequencies of the HLA-DR alleles in Mexican patients with ashy dermatosis and compare them with ethnically matched healthy control subjects to reveal the genetic susceptibility to develop ashy dermatosis. METHODS: We included 23 consecutive patients with clinical and histopathologic confirmed diagnosis of erythema dyschromicum perstans. Patients and control subjects received a questionnaire to determine their ethnic origin and a peripheral blood sample was taken for DNA extraction. Finally, Genetic HLA-DRB1 was performed by polymerase chain reaction sequence-specific oligonucleotide reverse dot blot hybridization. RESULTS: Of the 23 patients included in this study, 65% were women and 35% were men. We observed that the disease was located in the trunk in 17 patients (74%) and the upper limbs in 15 patients (65%). The most frequent allele was HLA-DR4 (65%) (pC < 1 x 10(-6), odds ratio = 6.0, 95% confidence interval = 2.8-12.7) whereas in control subjects it was 23%. The most frequent molecular subtype in both patients and healthy control subjects was DRB1( *)0407, being statistically significant after comparing the two groups (pC < 1 x 10(-6), odds ratio = 7.0, 95% confidence interval = 3.1-15.8). LIMITATIONS: Since this is a disease strongly influenced by ethnicity, extrapolation to other ethnic groups is limited. CONCLUSIONS: Many factors influence the ethiopathogenesis of erythema dyschromicum perstans, but it is strongly suggested to have an important genetic susceptibility conferred by genes located within the major histocompatibility complex region.