[Scrofuloderma, cutaneous and pulmonary tuberculosis associated with COVID-19. Report of one case]

Cutaneous tuberculosis represents 1-1.5% of extrapulmonary tuberculosis, including a variety of clinical conditions. Scrofuloderma and lupus vulgaris are the most common forms. We report a 49-year-old woman who sought medical attention through tele-dermatology concerning a cervical nodule associated with suppuration and cutaneous involvement. The diagnoses of scrofuloderma and pulmonary tuberculosis were confirmed, and during her evolution she presented a coinfection with SARS-CoV-2. The possible associations between tuberculosis and COVID-19 were reviewed.

Cutaneous Metastasis From Parotid Tumors: A Report of 2 Cases and Literature Review

ABSTRACT

Cutaneous metastases from parotid tumors are uncommon and imply a poor prognosis. In this article, we report 2 new cutaneous metastasis cases from 2 different parotid malignancies and 42 additional cases from a literature review. Clinical manifestations, localization, and outcomes of skin metastasis from parotid tumors are described. Although infrequent, parotid neoplasms may develop skin metastasis many years after the initial diagnosis, mostly in the head and neck region. Therefore, long-term follow-up and periodic skin examination of these patients is mandatory. Dermatologists and surgeons must have a high index of suspicion when evaluating any skin lesion arising on these patients because cutaneous metastasis from parotid neoplasms generally implies a poor prognosis.

Mycosis Fungoides, Lymphomatoid Papulosis and Hodgkin's Lymphoma in the Same Patient: Apropos of a Possible Monoclonal Origin

A 59-year-old man with Hodgkin's lymphoma was referred by a hematologist for consultation for cutaneous issues. Physical examination revealed generalized scaling and erythematous scaly patches located in the groin, abdomen, and arms. The biopsy was compatible with mycosis fungoides (MF). At his next medical visit, painful nodules with erythematous halo and scabby surface were noted, and a subsequent biopsy was compatible with lymphomatoid papulosis (LyP). Mycosis fungoides, the most common primary cutaneous T-cell lymphoma, is usually defined in its classic form as a CD4⁺ non-Hodgkin lymphoma; LyP corresponds to a CD30⁺ lymphoproliferative disorder; and Hodgkin's lymphoma (HL) constitutes a lymphoid neoplasia characterized by the presence of Reed-Sternberg cells and its variants. Although these entities have been defined independently, evidence suggests the possibility of a common monoclonal origin. To our knowledge, this is the first case of MF, LyP, and HL in a single patient.

Focal Rosai-Dorfman disease coexisting with lymphoma in the same anatomic site: a localized histiocytic proliferation associated with MAPK/ERK pathway activation

Rosai-Dorfman disease is a rare histiocytic disorder shown to have gene mutations that activate the MAPK/ERK pathway in at least one-third of cases. Most patients with Rosai-Dorfman disease present with bulky lymphadenopathy or extranodal disease, but rarely Rosai-Dorfman disease is detected concomitantly with lymphoma in the same biopsy specimen. The underlying molecular mechanisms of focal Rosai-Dorfman disease occurring in the setting of lymphoma have not been investigated. We report 12 cases of Rosai-Dorfman disease and lymphoma involving the same anatomic site. There were five men and seven women (age, 23 to 77 years) who underwent lymph node (n = 11) or skin (n = 1) biopsy; the lymphomas included nodular lymphocyte predominant Hodgkin lymphoma (n = 6), classical Hodgkin lymphoma (n = 4), small lymphocytic lymphoma (n = 1) and extranodal marginal zone lymphoma (n = 1). The foci of Rosai-Dorfman disease in all cases had S100 protein-positive histiocytes undergoing emperipolesis. No patients had Rosai-Dorfman disease at other anatomic sites at initial diagnosis and at last follow-up (median, 40 months). We performed immunohistochemical analysis to assess activity of the MAPK/ERK pathway in the Rosai-Dorfman disease foci. We also micro-dissected disease foci and analyzed 146 genes using next-generation sequencing in four cases with adequate DNA; the panel included genes previously reported to be mutated in Rosai-Dorfman disease. All cases were negative for gene mutations. Nevertheless, all cases were positive for cyclin D1 and most cases showed p-ERK expression indicating that the MAPK/ERK pathway is active in the histiocytes of focal Rosai-Dorfman disease. We conclude that focal Rosai-Dorfman disease coexisting with lymphoma is a clinically benign and localized histiocytic proliferation. These data also indicate that the MAPK/ERK pathway is active in focal Rosai-Dorfman disease although we did not identify activating mutations. These findings suggest that the pathogenesis of focal Rosai-Dorfman disease is different from that of usual cases of Rosai-Dorfman disease.

[Extranodal Natural Killer/T-Cell Lymphoma, nasal-type with primary cutaneous involvement. A case report]

INTRODUCTION

Extranodal natural killer/T-cell lymphoma (NK/T), nasal type, is an infrequent neoplasm with a high lethality, characterized by bone destruction around the sinus, nasal septum or obstruction of the airway. Also, may be primary skin involvement, airway and other organs. Objecti ve: Submit a rare condition in the pediatric population, in order to facilitate the diagnostic suspicion and quick recognition from specialists.

CASE REPORT

a 14-year-old girl, who presented arm and leg lesions, painless, suggestive of subcutaneous panniculitis, which evolve to ulcerated purple maculae. Skin biopsy showed lesion compatible with NK/T lymphoma, nasal type. She was referred to pedia tric oncology, where she received chemotherapy treatment. Despite medical efforts, the patient died eight months after due to a serious pulmonary infection secondary to immunosuppression. Conclu sions: Extranodal NK/T-cell lymphoma, nasal type, is a rare neoplasm that behaves aggressively, with high mortality without treatment, therefore, its recognition has a high importance for early diagnosis and prompt referral to Hematology-Oncology.

Immunohistochemical expression of vitamin D receptor in melanocytic naevi and cutaneous melanoma: a case-control study

BACKGROUND

Vitamin D deficiency is associated with higher risk of cancer, possibly due to its antiproliferative, antiangiogenic, proapoptotic, cell-differentiating and anti-invasive effects. The anticarcinogenic role of vitamin D in melanoma is still a matter of debate. Loss of nuclear and cytoplasmic vitamin D receptor (VDR) expression in melanoma cells has been reported.

OBJECTIVES

To analyse VDR immunohistochemical expression in benign dermal naevi (DN) and malignant melanoma (MM).

METHODS

A case-control study evaluated nuclear and cytoplasmic VDR immunohistochemical staining in 54 DN and 55 MM tissue samples.

RESULTS

There was significantly higher cytoplasmic VDR positivity in DN compared with MM (59% vs. 16%, P < 0·001). The mean VDR cytoplasmic expression was also higher in DN vs. MM (P < 0·001). No differences in nuclear VDR positivity were observed between groups, but mean nuclear VDR expression was significantly lower in DN vs. MM (P = 0·02). The loss of cytoplasmic VDR in MM was associated with Clark level, tumour staging and American Joint Committee on Cancer pTNM staging (P=0·004, 0·009 and 0·02, respectively).

CONCLUSIONS

Alterations in VDR expression and localization are found in MM compared with DN. Loss of cytoplasmic VDR was associated with melanoma tumour size, suggesting that loss of cytoplasmic VDR may be a prognostic factor.

[Understanding current therapies in metastatic melanoma]

Cutaneous melanoma is a highly aggressive tumor developing from melanocytes, its incidence is increasing, and prognosis in advanced stages is daunting. New therapies have been approved during the recent years with unprecedented results, including inhibitors of MAPK/ERK pathway and immune checkpoint blockade (anti-cytotoxic T lymphocyte antigen-4 (CTLA-4) as ipilimumab, anti-programmed cell death protein 1 (PD-L1) as pembrolizumab and anti-programmed cell death protein 1 ligand (PD-L1), among many others). The aim of this paper is to review currently available metastatic melanoma therapies focusing mainly on new therapies that have demonstrated effectiveness, after several decades of little progress in the treatment of this disease.

The use of a sunscreen containing DNA-photolyase in the treatment of patients with field cancerization and multiple actinic keratoses: a case-series

Cutaneous field cancerization (CFC) is associated witha high-risk of developing cutaneous squamous cellcarcinoma (cSCC). It manifests as actinic keratoses(AK) as one of the few macroscopic alterations in CFCpatients. A prospective, single-arm, case-series wasperformed to evaluate the utility of a novel sunscreencontaining DNA-photolyase for treatment of CFCin nine subjects (mean age 70.6 years, male: femaleratio 5:4). The cream was applied topically twicedaily on CFC/AK areas and patients were followedup for three months, with no other treatments. Theprimary outcome was the overall response rate (ORR),categorized as complete response (CR, completeresolution of AKs), partial response (PR, reduction inthe number of AKs), and no-response (NR, similar/increase in number of AKs). A 100% PR was observed.All subjects displayed at minimum, a 50% reductionin their lesion number and most patients experiencedalmost CR. Evaluation of AK numbers revealed anabsolute count reduction of 76.6% in the number oflesions, with the mean number of lesions reducedfrom 13.4 to 3.1 (p &lt; 0.0001). No adverse events werereported. Patients with CFC may benefit from noveltopical applications containing DNA-photolyase,at minimum, as complementary therapy for themanagement of CFC disease. We propose a newconcept called "active photoprotection" because of itsdual mechanism involving therapy and protection.

[Sézary syndrome treated with extracorporeal photopheresis: Report of one case]

Sézary syndrome (SS) is an unusually aggressive T- cell lymphoma characterized by the triad of erythroderma, the presence of more than 1,000 Sézary cells in peripheral blood and lymphadenopathies. It is accompanied by generalized pruritus and poor quality of life. The management of SS depends on its stage, patient comorbidities, and treatment availability. Extracorporeal photopheresis (ECP) is the first line of treatment for patients with T-cell lymphomas in stage IVA1, IVA2 or SS. This treatment comprises three phases: leukapheresis, photoactivation and subsequent reinfusion of lymphocytes. As it is an immunomodulatory therapy it does not produce generalized immunosuppression. We report a 76 year-old male with SS stage IIIb initially treated with 12 sessions of ultraviolet phototherapy without response. After 10 well-tolerated sessions of ECP, itching and skin lesions eventually disappeared.

[Primary cutaneous anaplastic large cell lymphoma: Report of one case]

Primary cutaneous anaplastic large cell lymphoma (PCALCL) is within the spectrum of cutaneous CD30-positive lymphoproliferative disorders. It presents as localized or multifocal tumors or plaques and carries an excellent long-term prognosis even in cases with regional and/or ipsilateral lymph node involvement or in cases of recurrent disease. We report a 34 year-old female with a thigh lesion. Skin biopsy confirmed the diagnosis of PCALCL. The patient was strictly monitored but no treatment was instituted and the tumor regressed spontaneously. After 24 months of follow-up the patient remains free of disease without new lesions.

Cutaneous manifestations in renal transplant recipients of Santiago, Chile

INTRODUCTION

Renal transplant recipients have a heightened risk of developing various cutaneous manifestations, such as skin infections, skin cancer, and secondary effects of immunosuppressive drugs. These manifestations differ depending on the evaluated population. The objective of this study was to describe the prevalence of cutaneous manifestations among renal transplant recipients in Chile between 1979 and 2008.

METHODS

Patients were recruited and then evaluated using a standardized questionnaire. Dermatologic physical examination was performed in every patient describing skin lesions, immunosuppressive drug effects, and malignant diseases. All suspicious lesions were biopsied for analysis. Every patient was queried for the development of skin cancer after his or her transplantation.

RESULTS

A total of 91 patients were enrolled; ages 10-67 years. Sixty percent of the patients presented with an infection at the initial evaluation. The most common infection was onychomycosis (58%) and verruca vulgaris (25%). In this study 58% of patients developed cutaneous side effects of immunosuppressive drugs. Among the evaluated patients, 16% showed premalignant or malignant manifestations on physical examination. The most frequent manifestations were actinic keratosis (17%), basal cell carcinoma (1%), and squamous cell carcinoma (1%). On a retrospective analysis, 12% of patients developed skin cancer after transplantation, 66% squamous cell carcinoma and 34% basal cell carcinoma, with a ratio of 1.9 to 1.

DISCUSSION

Cutaneous manifestations in renal transplant recipients are generally secondary to immunosuppression. These patients show a greater risk of having human papilloma virus (HPV) infections and nonmelanoma skin cancer. Periodic dermatologic evaluation of these patients should be performed to detect early lesions and modify risk factors.

Tanning salons in Santiago, Chile: the knowledge of the staff in charge and the quality of information provided to potential clients before and after a new regulatory law

INTRODUCTION

In recent years, the use of artificial tanning devices has become very popular in Chile. In April, 2007, a new law was established to regulate the non-medical use of tanning beds and tanning booths. The aim of this study was to evaluate the level and quality of information provided by tanning salon staff to clients before deciding on using the services. This information was collected before and 6 months after the law was enacted by researchers visiting tanning salons posing as potential clients.

METHODS

Using a previously designed questionnaire, 24 tanning salons in Santiago, Chile, were evaluated by researchers acting as potential customers without experience with artificial tanning devices. Employees were questioned using a hidden questionnaire before and 6 months after enactment of the law.

RESULTS

Before the law, 25% of the establishments gave spontaneous information about the risks of using tanning beds, which increased to 45.8% after enactment of the law. Clients never received written information, either before or after enactment of the law. On both evaluations, more than 1/3 of the employees affirmed that there were no risks in using tanning beds. Before enactment of the law, only 12.5% of the tanning salons required the use of goggles, while after the law, this increased to 25% (P=NS). Only two establishments required that clients sign an informed consent form after enactment of the law.

DISCUSSION

The level of knowledge among employees in tanning salons was very low and the quality of the information they provided to the clients was very poor. It was important to legislate on ultraviolet tanning services, but at present, the impact of the law has been very limited.

[Use of intravenous immunoglobulin for the treatment of toxic epidermal necrolysis and Stevens-Johnson/toxic epidermal necrolysis overlap syndrome. Review of 15 cases]

BACKGROUND

Toxic epidemial necrolysis (TEN) is an acute adverse drug reaction, that has an unpredictableprogression and a 30% mortality. The incidence of TEN in the general population is approximately 0.4 to 1.2 cases/million/year. It is characterized pathologically by keratinocyte apoptosis which leads to epidemial detachment. Keratinocyte apoptosis is triggered by activation of the Fas-FasL, pathway and could be prevented by the use of intravenous immunoglobulin (IVIG).

AIM

To report the experience with the use of IVIG in TEN.

MATERIAL AND METHODS

Retrospective study of 15 patients with a diagnosis of Stevens-Johnson/TEN overlap (SJS/TEN) or TEN, that received a total dose of 23 +/- 0.6 mg/kg ofIVIG over aperiod of 3 to 4 days. The infusión was initiated during thefirst 24 hours after diagnosis and was associated with standard care for burn victims. Steroids were avoided if the patient was not in chronic steroidal therapy.

RESULTS

Allpatients responded to IVIG in a lapse of 46.4 +/- 14.2 hours from the beginning of infusión. Eighty percent of patients survived, but one developed acute renal failure due to IVIG, and another became blind due to corneal opacities, a complication of TEN. Those who survived were discharged after a lapse of 19-8 +/- 6.6 days from the beginning ofthe disease.

CONCLUSIONS

Despite the lack of blind, multicentric and randomized triáis, we agree with some international studies that TVIG is beneficial as a treatment for SSJ/NETand TEN .

[Sun exposure behaviors and knowledge among Chileans]

BACKGROUND

Ultraviolet light exposure has a pathogenic effect on the development of skin cancer, whose prevalence increases worldwide. In Chile and the rest of the world, preventive educational campaigns are carried out to change high risk sun exposure behaviors.

AIM

To study the behavior of the Chilean population towards skin cancer prevention and to identify erroneous preventive practices and concepts.

MATERIAL AND METHODS

A survey containing 17 questions about sun exposure behaviors, photoprotective measures and knowledge about ultraviolet radiation and skin cancer was used. It was applied during January and February 2004, to 1,143 subjects (mean age 30 years, 409 males), taking vacations in beach resorts in Chile.

RESULTS

The hours of higher sun exposure ranged from 12 AM to 4 PM. Thirty seven percent of subjects were exposed more than 2 hours during this high risk lapse. Women and subjects aged less than 25 years were those with the riskiest behaviors. Fifty four percent used some type of photoprotection and 50% used ocular protection. Seventy percent used creams with sun screen and 74% used a sun protection factor higher than 15. Seventy percent applied the sun screen as recommended. Thirty eight percent had at least one sun burn in the last two years. More than 90% of subjects were aware of the relationship between sun exposure and skin cancer but 60% did not know the hours of higher ultraviolet radiation. The information about sun exposure was obtained from television in 57% of surveyed individuals.

CONCLUSIONS

More educational campaigns about the risk of sun exposure are needed to reduce risky behaviors in the Chilean population.

[Toxic epidermal necrolysis. Therapy in ICU with intravenous immunoglobulins in a case]

We report a 27 years old homosexual male with AIDS that was admitted to the ICU dehydrated, with fever and severe malaise. He had irregular bullae, an extensive purpuric exanthema and a zone of epidermic detachment in the right arm. A toxic epidermal necrolysis was diagnosed and therapy with i.v. immunoglobulins was started. After four days of treatment, bullous lesions disappeared and the extension of exanthema decreased. Toxic epidermal necrolysis is a potentially fatal disease and the use of intravenous immunoglobulins for this condition has been reported as successful.

Primary cutaneous angioplasmocellular hyperplasia

Two cases of solitary nodules on the skin of the trunk of young adults showing a peculiar pattern of proliferation of blood vessels and a mixed inflammatory infiltrate with predominance of polyclonal plasma cell infiltration are presented. Follow-up of these patients after complete surgical excision revealed no recurrence. We interpreted the lesions within the morphologic spectrum of plasma cell infiltrates of the skin to be reactive and/or hyperplastic, which we term primary cutaneous angioplasmocellular hyperplasia.

Free laminar thin band graft--a surgical therapeutic variant in the treatment of leg ulcers

For the past 2 years, we have been using a surgical technique for the treatment of leg ulcers caused by chronic venous insufficiency. This consists of a type of graft biologically and technically intermediate between Reverdin and Thiersh's types. We have named it the "free laminar thin band graft." In contrast to the Thiersh graft, this simple surgical technique requires little equipment, and it can be done quickly and easily as an office procedure, with little risk to the patient. In addition, it is a low cost procedure. In our experience with this technique, healing time is shorter and lesions recur later than with the Reverdin graft. The authors describe the surgical method and report a clinical case.