A single educational intervention aiming to improve dermatology care in western Nepal.

BACKGROUND: There is limited dermatologic training available for healthcare workers in Nepal. METHODS: We visited a rural area of western Nepal to set up a pilot program of dermatologic teaching. This consisted of 2 days of interactive lectures, followed by 2 days of practical dermatology in the clinic. RESULTS: After the theoretical training, the overall accuracy of the diagnoses made by the attendees was high at 79%. All trainees felt that the program had been useful. The most common conditions seen were eczema and skin infection. CONCLUSION: We aim to expand this dermatologic training program in western Nepal in the future.

Atypical cutaneous leishmaniasis in two patients receiving low-dose methotrexate.

Cutaneous leishmaniasis is a protozoan disease that has high morbidity. There have been increasing reports of leishmaniasis in patients with an underlying immunosuppressed state. We present two cases of cutaneous leishmaniasis caused by Old World species in patients on methotrexate therapy. We postulate that the T-cell-mediated response to leishmaniasis infection could be modulated by methotrexate and may render an immunosuppressed individual more susceptible to developing clinical disease.

Clinical features and diagnosis of 42 travellers with cutaneous leishmaniasis.

BACKGROUND: Leishmania species that occur within different geographical areas may cause different clinical manifestations, virulence and drug sensitivity. Patients/Methods. All patients with a clinical diagnosis of cutaneous leishmaniasis seen at the Hospital for Tropical Diseases from 1997 to 2000 were identified and clinical details recorded onto a database, with emphasis on clinical presentation, risk factors, travel history and laboratory diagnosis. RESULTS: Forty-two patients were identified, 23 of whom had travelled to New World and 19 to Old World countries. Clinical presentation typically consisted of a single nodule with ulceration. In 50% infection was caused by L. (Viannia) braziliensis. PCR was performed in specimens from 34 patients and species identification was possible in 32 cases (sensitivity 94%), the two PCR negative patients had amastigotes demonstrated by histology and culture. Patients were treated with established therapies. Seventy one percent were cured by treatment, 12% had a spontaneous cure, 7% were lost to follow-up and the remaining 10% required a second-line therapy. No relapses were reported during a mean follow-up period of 27 months. CONCLUSIONS: Our study highlights the need for comprehensive investigations and the advantages of PCR in the diagnosis of patients with suspected leishmaniasis in non-endemic regions of the world.

Cutaneous leishmaniasis: three children with Leishmania major successfully treated with itraconazole.

We report the rare instance of four family members with numerous cutaneous lesions of Leishmania major contracted while on holiday in Algeria. Treatment was successful with oral itraconazole for the children and intralesional sodium stibogluconate for the mother. Cutaneous leishmaniasis should be considered in those with apparently sterile plaques returning from endemic areas. These results suggest that itraconazole, which is ideally suited for use in children, is an effective monotherapy for L. major.

Inmunoglobulinas en pacientes con actinomicetoma por Nocardia brasiliensis / Immunoglobulins in patients with Nocardia brasiliensis actinomycetoma

Considerando que algunos autores han reportado un aumento en la cantidad de algunas inmunoglobulinas en los pacientes con actinomicetoma, en este trabajo nos propusimos determinar diferencias en la producción de IgG1, IgG2, IgG3, IgG4 e IgM en 25 pacientes con actinomicetoma por Nocardia brasiliensis y 25 personas sanas provenientes de una zona endémica de micetoma. La determinación de inmunoglobulinas se realizó por medio de la técnica de ELISA. Para sensibilizar las placas se emplearon 6 antígenos de N. brasiliensis: un antígeno crudo denominado NB y cinco derivados del mismo (NB2, NB4, NB6, NB8 y NB10) separados por punto isoeléctrico. Los niveles de las cuatro subclases de IgG fueron mayores en los sueros de los pacientes que en el suero de los controles, con una diferencia máxima en IgG3 e IgG4; para esta última subclase, los seis antígenos fueron altamente reactivos. La concentración de IgM fue igual en ambos grupos. Es probable que como ocurre en otras infecciones, en la fisiopatogenia del actinomicetoma influya no sólo el aumento o deficiencia de una clase de inmunoglobulina, sino la relación que existe entre las diferentes subclases.

Considering that some authors have reported an increasing of some immunoglobulins in actinomycetoma patients, in this study we propose to determine differential production of IgG1, IgG2, IgG3, IgG4 and IgGM in 25 patients with actinomycetoma and 25 healthy individuals from a mycetoma endemic area. Immunoglobulins were determined by ELISA technique. To sensibilize the plates, six Nocardia brasiliensis antigens were used: a crude antigen denominated NB and five derivatives (NB2, NB4, NB6, NB8 and NB10) obtained by their isoelectric point. Results showed that all IgG subclasses were higher in the patients’ sera than in control sera, with a maximal difference to IgG3 and IgG4. To the latter subclass, six antigens were highly reactives. IgM levels were similar in both groups. As it occurs in other infections, in the actinomycetoma pathogenesis probably participate the increase or deficiency of a determined immunoglobulin class, as well as the relationship between different subclasses.

Sweet's syndrome and a Mirena intrauterine system.

A woman fitted with a Mirena intrauterine system (IUS) for menorrhagia presented with a short history of fever and progressive skin lesions. Histological examination of a skin biopsy was compatible with the clinical diagnosis of Sweet's syndrome. Treatment was with topical and oral steroids, however the condition relapsed on reduction of the steroid dose. Symptoms finally resolved on removal of the IUS and the patient remained symptom free at 9-month follow-up. There have been previous reports of Sweet's syndrome in association with hormonal contraceptives, however this is believed to be the first reported case in association with a Mirena IUS.

[Immunoglobulins in patients with Nocardia brasiliensis actinomycetoma]. / Inmunoglobulinas en pacientes con actinomicetoma por Nocardia brasiliensis.

Considering that some authors have reported an increasing of some immunoglobulins in actinomycetoma patients, in this study we propose to determine differential production of IgG1, IgG2, IgG3, IgG4 and IgGM in 25 patients with actinomycetoma and 25 healthy individuals from a mycetoma endemic area. Immunoglobulins were determined by ELISA technique. To sensibilize the plates, six Nocardia brasiliensis antigens were used: a crude antigen denominated NB and five derivatives (NB2, NB4, NB6, NB8 and NB10) obtained by their isoelectric point. Results showed that all IgG subclasses were higher in the patients' sera than in control sera, with a maximal difference to IgG3 and IgG4. To the latter subclass, six antigens were highly reactives. IgM levels were similar in both groups. As it occurs in other infections, in the actinomycetoma pathogenesis probably participate the increase or deficiency of a determined immunoglobulin class, as well as the relationship between different subclasses.

Inmunoglobulinas en pacientes con actinomicetoma por Nocardia brasiliensis. / [Immunoglobulins in patients with Nocardia brasiliensis actinomycetoma]

Considering that some authors have reported an increasing of some immunoglobulins in actinomycetoma patients, in this study we propose to determine differential production of IgG1, IgG2, IgG3, IgG4 and IgGM in 25 patients with actinomycetoma and 25 healthy individuals from a mycetoma endemic area. Immunoglobulins were determined by ELISA technique. To sensibilize the plates, six Nocardia brasiliensis antigens were used: a crude antigen denominated NB and five derivatives (NB2, NB4, NB6, NB8 and NB10) obtained by their isoelectric point. Results showed that all IgG subclasses were higher in the patients sera than in control sera, with a maximal difference to IgG3 and IgG4. To the latter subclass, six antigens were highly reactives. IgM levels were similar in both groups. As it occurs in other infections, in the actinomycetoma pathogenesis probably participate the increase or deficiency of a determined immunoglobulin class, as well as the relationship between different subclasses.

New World cutaneous leishmaniasis in returned travellers: treatment failures using intravenous sodium stibogluconate.

Treatment outcome was determined among a cohort of travellers who returned to the UK between February 2000 and February 2001 with New World cutaneous leishmaniasis caused by species of the Leishmania (Viannia) subgenus. Among 18 patients who completed treatment with 20 mg/kg/d of i.v. sodium stibogluconate (NaSb) for 20 d, early relapse of disease occurred in 2 patients with regional dissemination in 1 and mucocutaneous involvement in the other. Drug susceptibility testing in vitro of the clinical isolate from 1 of these patients confirmed tolerance to high concentrations of NaSb.

Cutaneous larva migrans: clinical features and management of 44 cases presenting in the returning traveller.

BACKGROUND: Cutaneous larva migrans (CLM) is the result of a nematode infection, and shows a characteristic creeping eruption. As travel to the tropics increases, many British citizens may be returning with this infection, which is often misdiagnosed or treated incorrectly. OBJECTIVES: To perform a retrospective survey of 44 cases of CLM presenting to the Hospital for Tropical Diseases in London over the last 2 years. METHODS: Cases were reviewed with regard to patient characteristics, source of infection, source of referral, clinical features and therapy. RESULTS: Most infections were acquired in Africa (32%), the Caribbean (30%) and South-east Asia (25%), but also in Central and South America. There was a history of exposure to a beach in 95% of patients and the median duration of symptoms was 8 weeks (range 1-104). Lesions mainly affected the feet (39%), buttocks (18%) and abdomen (16%), but the lower leg, arm and face were also affected. Multiple lesions were seen in seven of 44 cases (16%). Laboratory abnormalities were absent in all patients. Of 44 patients seen, four needed no treatment, 28 were cured by a single course of treatment, 11 required a second course of therapy and one patient was treated three times. Thirty-one patients received oral albendazole 400 mg daily for 3-5 days and 24 were cured (77%). Five patients received 10% thiabendazole cream topically for 10 days and four were cured (80%). Four patients received oral thiabendazole 1.5 g daily for 3 days and all required further therapy. CONCLUSIONS: In view of the range of treatment regimens recorded, a randomized controlled trial comparing topical and systemic therapies is warranted.

Presence of human T-cell responses to the Mycobacterium leprae 45-kilodalton antigen reflects infection with or exposure to M. leprae.

The ability of the 45-kDa serine-rich Mycobacterium leprae antigen to stimulate peripheral blood mononuclear cell (PBMC) proliferation and gamma interferon (IFN-gamma) production was measured in leprosy patients, household contacts, and healthy controls from areas of endemicity in Mexico. Almost all the tuberculoid leprosy patients gave strong PBMC proliferation responses to the M. leprae 45-kDa antigen (92.8%; n = 14). Responses were lower in lepromatous leprosy patients (60.6%; n = 34), but some responses to the 45-kDa antigen were detected in patients unresponsive to M. leprae sonicate. The proportion of positive responses to the M. leprae 45-kDa antigen was much higher in leprosy contacts (88%; n = 17) than in controls from areas of endemicity (10%; n = 20). None of 15 patients with pulmonary tuberculosis gave a positive proliferation response to the 45-kDa antigen. The 45-kDa antigen induced IFN-gamma secretion similar to that induced by the native Mycobacterium tuberculosis 30/31-kDa antigen in tuberculoid leprosy patients and higher responses than those induced by the other recombinant antigens (M. leprae 10- and 65-kDa antigens, thioredoxin, and thioredoxin reductase); in patients with pulmonary tuberculosis it induced lower IFN-gamma secretion than the other recombinant antigens. These results suggest that the M. leprae 45-kDa antigen is a potent T-cell antigen which is M. leprae specific in these Mexican donors. This antigen may therefore have diagnostic potential as a new skin test reagent or as an antigen in a simple whole-blood cytokine test.

Sequence and immunological characterization of a serine-rich antigen from Mycobacterium leprae.

Sera from lepromatous leprosy patients were used to screen a Mycobacterium leprae lambda gt11 library. Three positive plaques were picked, and lysogens were constructed. Immunoblot analysis showed that all of the lysogens expressed an apparently identical beta-galactosidase fusion protein which reacted strongly with the sera. The 1.7-kbp insert from one clone was subcloned into the lacZ gene in pUR290; sequence analysis of the end fused to lacZ revealed an open reading frame with no significant homology to previously published sequences. The insert was used to screen an M. leprae cosmid library, and five clones were isolated. The insert was also found to hybridize to clones expressing the M. leprae antigen which had previously been designated class III and 25L. A 1.8-kbp HindIII fragment was subcloned from one of the cosmids and sequenced. The sequence revealed a 1,227-bp open reading frame, encoding a 408-amino-acid protein with a predicted molecular mass of 42,466 Da. The protein contains amino- and carboxy-terminal hydrophobic domains and a hydrophilic central domain; the amino-terminal domain shows some homology to a 51-kDa hypothetical antigen of Mycobacterium tuberculosis, while the hydrophilic region contains a high proportion of serine residues, and we have therefore designated the protein serine-rich antigen (Sra). Some repeated motifs are present in the protein, but their significance is unknown. Seventy-eight percent of serum samples from multibacillary leprosy patients and 68% of serum samples from paucibacillary leprosy patients recognized the fusion protein, showing that this is a major M. leprae antigen. In contrast, all serum samples from endemic controls were negative, while 26% of serum samples from tuberculosis patients were weakly positive.