Infections in the era of immunobiologicals

Immunobiologicals represent an innovative therapeutic option in dermatology. They are indicated in severe and refractory cases of different diseases when there is contraindication, intolerance, or failure of conventional systemic therapy and in cases with significant impairment of patient quality of life. The main immunobiologicals used in dermatology basically include inhibitors of tumor necrosis factor-alpha (anti-TNF), inhibitors of interleukin-12 and -23 (anti-IL12/23), inhibitors of interleukin-17 and its receptor (anti-IL17), inhibitors of interleukin-23 (anti-IL23), rituximab (anti-CD20 antibody), dupilumab (anti-IL4/IL13) and intravenous immunoglobulin. Their immunomodulatory action may be associated with an increase in the risk of infections in the short and long term, and each case must be assessed individually, according to the risk inherent to the drug, the patient general condition, and the need for precautions. This article will discuss the main risks of infection associated with the use of immunobiologicals, addressing the risk in immunocompetent and immunosuppressed patients, vaccination, fungal infections, tuberculosis, leprosy, and viral hepatitis, and how to manage the patient in the most diverse scenarios.

Clinical characterization, physical frailty, and depression in elderly patients with psoriasis from a reference center in Brazil: a cross-sectional study

BACKGROUND

There are few studies dedicated to the characterization of the geriatric population with psoriasis, which has particularities in terms of clinical manifestations and therapeutic limitations. As psoriasis is a chronic disease, presenting a higher prevalence with age, the increase in life expectancy in Brazil demands knowledge about the behavior of the disease among the elderly.

OBJECTIVES

To characterize elderly people with psoriasis from a tertiary service, from the clinical-epidemiological point of view, presence of comorbidities, physical frailty, and affective impact, and to compare these aspects with adults with psoriasis and elderly people without the disease.

METHODS

Cross-sectional study of 64 elderly patients with psoriasis, 64 adults with psoriasis, and 64 elderly patients without the disease. Clinical-demographic aspects, the Beck depression scale, and Skindex-16 were evaluated. Indicators of physical frailty were evaluated in elderly patients: handgrip, sit-to-stand test, fatigue, and weight loss >5%.

RESULTS

In the elderly, the mean age (SD) of psoriasis onset was 44 (10) years, men represented 47% of the sample, the prevalence of arthritis was 22%, and ungual involvement occurred in 72%. Topical corticosteroids were used more often among elderly people with psoriasis (100%) than among adults with the disease (86%), with no difference among other systemic treatments. Diabetes mellitus occurred in 30% of the elderly. Hypertension (59%), dyslipidemia (52%), depression (34%), and fatigue (59%) were more prevalent among the elderly with psoriasis than among the healthy controls.

STUDY LIMITATIONS

The study was carried out in a public reference service for patients with psoriasis, all of which were undergoing treatment.

CONCLUSIONS

Elderly people with psoriasis from a tertiary service showed greater affective impairment, metabolic comorbidities, and physical frailty than elderly controls.

Intestinal microbiome characterization of adult Brazilian men with psoriasis compared to omnivore and vegetarian controls

BACKGROUND

Psoriasis is a chronic inflammatory disease associated with systemic inflammation and comorbidities. Changes in the composition of the intestinal microbiome are involved in the pathogenesis of inflammatory diseases and metabolic syndrome. Characterizing the intestinal microbiome of patients with psoriasis may be relevant for the understanding of its clinical course and comorbidity prevention.

OBJECTIVE

To characterize the intestinal microbiome of men with psoriasis compared to omnivore and vegetarian controls (without psoriasis).

METHOD

Cross-sectional study of 42 adult males: 21 omnivores with psoriasis; and controls: 14 omnivores and 7 vegetarian individuals. The characterization of the intestinal microbiome was performed by metagenomic analysis. Serum levels of lipopolysaccharide-binding protein (LPB) and C-reactive protein (CRP) were evaluated.

RESULTS

The groups differed from each other regarding nutritional aspects and microbiome; individuals with psoriasis had a higher consumption of protein and lower consumption of fibers. Levels of LPB, CRP, and the Firmicutes/Bacteroidetes ratio were higher in the group with psoriasis than in the vegetarian group (p<0.05). The genera Prevotella, Mogibacterium, Dorea, Bifidobacterium and Coprococcus, differed in the group with psoriasis compared to vegetarians; the genera Mogibacterium, Collinsella and Desulfovibrio differed from omnivores. A microbiome pattern linked to psoriasis (plsPSO) was identified, which was associated with higher LPB levels (rho=0.39; p=0.02), and lower dietary fiber intake (rho=-0.71; p<0.01).

STUDY LIMITATIONS

Only adult men were evaluated.

CONCLUSION

A difference was identified in the intestinal microbiome of adult men with psoriasis when compared to healthy omnivores and vegetarian controls. The identified microbiome pattern was correlated with dietary fiber intake and serum levels of LPB.

Blastoid mantle cell lymphoma: cutaneous infiltration

Mantle cell lymphoma is an aggressive B-cell, non-Hodgkin’s lymphoma, with lymph node or extranodal origin, and a mean survival of three to five years. Skin involvement is rare, secondary and indicates neoplasia dissemination. The authors report a case of a female patient, 69 years old, diagnosed previously, after lymph node and bone marrow biopsy. She was undergoing the second chemotherapy regimen when she showed infiltrated plaque-like lesions, nodules and tumors on the trunk and thigh root. Histopathology and immunohistochemistry demonstrated cutaneous infiltration of the blastoid lymphoma.

Disseminated paracoccidioidomycosis in a liver transplant patient

Paracoccidioidomycosis is an endemic systemic mycosis caused by Paracoccidioides brasiliensis complex and P. lutzii. It is a rare disease in non-HIV-induced immunosuppressed individuals. In organ transplant recipients, it is more frequently associated with immunosuppression after kidney transplantation. In a liver transplant patient, only one case has been published in the literature to date. The present report comprises the case of a 47-year-old female patient with disseminated skin lesions associated with signs and symptoms of systemic involvement of paracoccidioidomycosis that manifested one year after liver transplantation and under an immunosuppression regimen with tacrolimus and mycophenolate mofetil.

Paracoccidioidomycosis: an uncommon clinical presentation

Paracoccidoiomycosis is a systemic mycosis with a higher incidence in males with history of exposure to the rural environment; its classic clinical manifestation is an oro-pulmonary lesion. The authors report a case of a female, urban, 76-year-old patient with atypical clinical-dermatological presentation and diagnostic conclusion after histopathological examination. The clinical response was quick and complete after treatment with itraconazole 400mg/day in the first month, decreased to 200mg/day until the sixth month of treatment.

Disseminated tuberculosis associated with reactive arthritis of Poncet in an immunocompetent patient

Cutaneous tuberculosis is a rare extrapulmonary manifestation of tuberculosis which, like disseminated tuberculosis, commonly occurs in immunocompromised patients. Poncet reactive arthritis is a seronegative arthritis affecting patients with extrapulmonary tuberculosis, which is uncommon even in endemic countries. We report a previously healthy 23-year-old male patient with watery diarrhea associated with erythematous ulcers on the lower limbs and oligoarthritis of the hands. Histopathological examination of the skin showed epithelioid granulomatous process with palisade granulomas and central caseous necrosis. AFB screening by Ziehl-Neelsen staining showed intact bacilli, the culture was positive for Mycobacterium tuberculosis, and colonoscopy revealed multiple shallow ulcers. Disseminated tuberculosis associated with reactive Poncet arthritis was diagnosed, with an improvement of the clinical and skin condition after appropriate treatment.

Assessment of psoriasis severity in Brazilian patients with chronic plaque psoriasis attending outpatient clinics: a multicenter, population-based cross-sectional study (APPISOT)

PURPOSE

Data on chronic plaque psoriasis severity and its potential clinical and lifestyle implications in the Brazilian population are limited. The primary aim of this study was to assess the clinical severity of plaque psoriasis in Brazil. Further objectives included evaluating potential associations between disease severity and demographic, lifestyle, and clinical characteristics, health-related quality of life (HRQOL), and work productivity.

MATERIALS AND METHODS

This observational (non-interventional) cross-sectional study was conducted in 26 dermatologic clinics across 11 Brazilian states. Psoriasis severity was assessed using investigator judgment and Finlay's Rule of Tens: a Psoriasis Area and Severity Index (PASI) score >10, a Body Surface Area (BSA) > 10%, or a Dermatology Life Quality Index (DLQI) score >10.

RESULTS

Among 1125 patients, 205 (18.2%) had moderate-to-severe disease. On multiple regression analyses, psoriasis severity was significantly (directly) associated with the presence of physical inactivity and comorbid pain, anxiety, and depression; and significantly (inversely) associated with HRQOL and work productivity.

LIMITATIONS

Cross-sectional studies cannot assess temporal trends, and observational studies cannot conclusively determine causality or exclude biases and confounding due to unmeasured variables.

CONCLUSIONS

Among Brazilian patients with moderate-to-severe psoriasis, disease severity had far-reaching adverse impacts on lifestyle, comorbidities, HRQOL, and work productivity.

Granuloma faciale: clinical, morphological and immunohistochemical aspects in a series of 10 patients

Granuloma faciale is a chronic, benign, cutaneous vasculitis with well-established clinical and morphological patterns, but with an unknown etiology. This study describes clinical and pathologic aspects of patients diagnosed with granuloma faciale. The authors analyzed demographic, clinical, morphological and immunohistochemical data from patients with a final diagnosis of granuloma faciale, confirmed between 1998 and 2012. There was a proportional and mixed inflammatory infiltrate, Grenz zones were present in almost all the samples. Immunophenotyping confirmed a higher intensity of T lymphocytes than B lymphocytes in thirteen samples, with a predominance of T CD8 lymphocytes in 64% of cases, in contrast to the literature, which indicates that the major component is T CD4 lymphocytes. All cases were positive for IgG4 but the majority (12/14) had less than 25% of stained cells. The pathogenesis of granuloma faciale remains poorly understood, making studies of morphological and immunohistochemical characterization important to better understand it.

Primary cutaneous plasmablastic lymphoma revealing clinically unsuspected HIV infection

Plasmablastic lymphoma is a rare subtype of diffuse large B-cell lymphoma more frequently diagnosed in immunosuppressed patients, mainly HIV-infected. Primary cutaneous plasmablastic lymphoma is extremely rare, and in this patient it was the first clinical manifestation of unsuspected HIV-infection.

Paracoccidioidomycosis: acute-subacute clinical form, juvenile type

The authors report aspects of paracoccidioidomycosis, acute-subacute clinical form, juvenile type, in a 19-year-old female patient. Paracoccidioidomycosis, juvenile type, classically occurs in young patients, both sexes, with lymphoma-like aspects as initial presentation. However, following the natural history of the disease the lymph nodes assume patterns of infectious disease, as an abscess and fistulae. Systemic dissemination of the disease can occur and lethality and morbidity are significant in this clinical presentation.

Scientific production of Brazilian dermatology: analysis of abstracts submitted at the Annual Meeting of the American Academy of Dermatology (2005 to 2013) and those eventually published

In the last decade the presence of Brazilian physicians in International Meetings of Dermatology has been expressive. In parallel it has also been expressive the submission of poster abstracts in those Meetings. Considering the meetings from 2005 to 2013, 379 posters were presented in meetings of the American Academy of Dermatology. Brazilian universities were the origin of 59.9%. The Brazilian Society of Dermatology's recognized residency programs were the origin of 69.9% of the presented posters. Considering the period from 2005 to 2010 (n = 165 posters) the papers effectively published were 19 (11.5%).

Hyaline fibromatosis syndrome: cutaneous manifestations

Hyaline fibromatosis syndrome is the current name for clinical manifestations of diseases previously known as "infantile systemic hyalinosis" and "juvenile hyaline fibromatosis". The authors report representative clinical cases of each one of the above subtypes with emphasis on cutaneous manifestations and difficulties for early diagnosis in this syndrome, essentially of multidisciplinary approach.

Toxigenic profile of methicillin-sensitive and resistant Staphylococcus aureus isolated from special groups

Background

Staphylococcus aureus is characterized by its pathogenicity and high prevalence, causing disease in both healthy and immunocompromised individuals due to its easy dissemination. This fact is aggravated by the widespread dissemination of S. aureus carrying toxigenic genes. The objective of this study was to determine the toxigenic profile of methicillin-sensitive S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) in patients with purulent skin and/or soft tissue infections seen at the Dermatology Department of the University Hospital of the Botucatu Medical School, asymptomatic adults older than 60 years living in nursing homes, and prison inmates of the Avaré Detention Center.

Methods

PCR was used for the detection of the mecA gene, enterotoxin genes (sea, seb, and sec), exfoliative toxins A and B (eta and etb), toxic shock syndrome toxin 1 (tst), panton–valentine leukocidin (lukS-PV and lukF-PV), and alpha- and delta-hemolysins or cytotoxins (hla and hld).

Results

The results showed a significant prevalence of toxigenic genes among S. aureus isolates from asymptomatic individuals, with the observation of a higher prevalence of cytotoxin genes. However, the panton–valentine leukocidin gene was only detected in MSSA isolated from patients with skin infections and the tst gene was exclusively found in MSSA isolated from prison inmates.

Conclusions

The present study demonstrated a significant prevalence of toxigenic genes in MSSA and MRSA strains isolated from asymptomatic S. aureus carriers. There was a higher prevalence of cytotoxin genes.

Neutrophil Extracellular Traps Identification in Tegumentary Lesions of Patients with Paracoccidioidomycosis and Different Patterns of NETs Generation In Vitro

Paracoccidioidomycosis (PCM) is a systemic mycosis, endemic in most Latin American countries, especially in Brazil. It is caused by the thermo-dimorphic fungus of the genus Paracoccidioides (Paracoccidioides brasiliensis and Paracoccidioides lutzii). Innate immune response plays a crucial role in host defense against fungal infections, and neutrophils (PMNs) are able to combat microorganisms with three different mechanisms: phagocytosis, secretion of granular proteins, which have antimicrobial properties, and the most recent described mechanism called NETosis. This new process is characterized by the release of net-like structures called Neutrophil Extracellular Traps (NETs), which is composed of nuclear (decondensed DNA and histones) and granular material such as elastase. Several microorganisms have the ability of inducing NETs formation, including gram-positive and gram-negative bacteria, viruses and some fungi. We proposed to identify NETs in tegumentary lesions of patients with PCM and to analyze the interaction between two strains of P. brasiliensis and human PMNs by NETs formation in vitro. In this context, the presence of NETs in vivo was evidenced in tegumentary lesions of patients with PCM by confocal spectrum analyzer. Furthermore, we showed that the high virulent P. brasiliensis strain 18 (Pb18) and the lower virulent strain Pb265 are able to induce different patterns of NETs formation in vitro. The quantification of extracellular DNA corroborates the idea of the ability of P. brasiliensis in inducing NETs release. In conclusion, our data show for the first time the identification of NETs in lesions of patients with PCM and demonstrate distinct patterns of NETs in cultures challenged with fungi in vitro. The presence of NETs components both in vivo and in vitro open new possibilities for the detailed investigation of immunity in PCM.

Paracoccidioidomycosis (PCM) is an infectious disease caused by fungi of genus Paracoccidioides (P. brasiliensis and P. lutzii). PCM is endemic in Latin America, with a greater incidence in Brazil, Colombia, and Argentina. Over the last years, studies are focusing on neutrophils’ (PMNs) actions against P. brasiliensis, due to the capacity of these cells to develop different defense strategies against pathogens. and especially due to constant presence of inflammatory infiltrates full of PMNs in the granuloma of the disease. As PMN release of both granular and nuclear material, identified as Neutrophil Extracellular Traps (NETs), is a spectacular action mechanism against microbes, we seek to identify whether this process would be an important mechanism triggered against P. brasiliensis. Thus, we showed for the first time the identification of NETs in tegumentary lesions of patients with PCM by viewing the individual components of NETs. Beyond that, we demonstrated the entrapment of P. brasiliensis in vitro by these structures released from human PMNs of patients with PCM and healthy donors, with different patterns, in a dependence of the evaluated strain. Our data provides important new information regarding the role of PMNs against P. brasiliensis, opening new avenues for the research on immunity of PCM.

Malignant syphilis in an immunocompetent female patient

Malignant syphilis is an uncommon manifestation of secondary syphilis, in which necrotic lesions may be associated with systemic signs and symptoms. Generally it occurs in an immunosuppressed patient, mainly HIV-infected, but might be observed on those who have normal immune response. Since there is an exponential increase in the number of syphilis cases, more diagnoses of malignant syphilis must be expected. We report a case in an immunocompetent female patient.

Community-associated methicillin-resistant Staphylococcus aureus in non-outbreak skin infections

The aim of this study was to determine the prevalence of Staphylococcus aureus and risk factors for the acquisition of MRSA (Methicillin Resistant Staphylococcus aureus) as the main cause of skin and soft tissue infections. S. aureus were characterized for the presence of PVL, TSST-1 and mecA genes. SCCmec typing was carried out in mecA positive strains and PFGE was performed only in these strains. During the study period, 127 outpatients attending a dermatology clinical the Botucatu Medical School, a regional tertiary hospital in Botucatu, Sao Paulo, Brazil, were diagnosed with active skin infections. A total 66 (56.9%) S. aureus strains were isolated. The methicillin resistance gene mecA was detected in seven (10.6%) S. aureus strains. The SCCmec types detected in the seven mecA-positive S. aureus strains were type Ia in one, type II in three, and type IV in three. The PVL gene was detected in 10 (15.1%) in sensitive strains. Pulsed field gel electrophoresis revealed non-clonal diversity among the isolates. The risk factors associated with MRSA acquisition in this study were previous ciprofloxacin use and working in a healthcare environment. The risk factors indicate plausible routes of CA-MRSA transmission among the subjects studied.

Herpes zoster-associated acute urinary retention in immunocompetent patient

Herpes zoster-associated urinary retention is an uncommon event related to virus infection of the S2-S4 dermatome. The possible major reasons are ipsilateral hemicystitis, neuritis-induced or myelitis-associated virus infection. We report a case of a 65-year-old immunocompetent female patient who presented an acute urinary retention after four days under treatment with valacyclovir for gluteal herpes zoster. The patient had to use a vesical catheter, was treated with antibiotics and corticosteroids and fully recovered after eight weeks.

Lepromatous leprosy and perianal tuberculosis: a case report and literature review

Leprosy is a chronic infectious disease caused by Mycobacterium leprae, a microorganism that usually affects skin and nerves. Although it is usually well-controlled by multidrug therapy (MDT), the disease may be aggravated by acute inflammatory reaction episodes that cause permanent tissue damage particularly to peripheral nerves. Tuberculosis is predominantly a disease of the lungs; however, it may spread to other organs and cause an extrapulmonary infection. Both mycobacterial infections are endemic in developing countries including Brazil, and cases of coinfection have been reported in the last decade. Nevertheless, simultaneous occurrence of perianal cutaneous tuberculosis and erythema nodosum leprosum is very rare, even in countries where both mycobacterial infections are endemic.

Cutaneous histoplasmosis disclosing an HIV-infection

Histoplasmosis is a systemic mycosis endemic in extensive areas of the Americas. The authors report on an urban adult male patient with uncommon oral-cutaneous lesions proven to be histoplasmosis. Additional investigation revealed unnoticed HIV infection with CD4+ cell count of 7/mm³. The treatment was performed with amphotericin B, a 2065 mg total dose followed by itraconazole 200mg/daily plus antiretroviral therapy with apparent cure. Histoplasmosis is an AIDS-defining opportunistic disease process; therefore, its clinical diagnosis must drive full laboratory investigation looking for unnoted HIV-infection.

Calciphylaxis: a rare but potentially fatal event of chronic kidney disease. Case report

Calciphylaxis or calcific uremic arteriolopathy is a rare cutaneous-systemic disease occurring in patients with advanced chronic kidney disease. The classical clinical picture is that of a necrotic and progressive skin ulcer of reticular pattern, mostly in the lower legs and susceptible to local infection. It is a product of mural calcification and occlusion of cutaneous and sub-cutaneous arteries and arterioles. The authors report the case of a 73-year-old male patient in his late stage of renal disease presenting severe necrotic cutaneous ulcers on lower legs followed by local and systemic infection and death due to sepse after parathyroidectomy.

Psoriasis: correlation between severity index (PASI) and quality of life index (DLQI) in patients assessed before and after systemic treatment

BACKGROUND

Psoriasis is a chronic inflammatory disease of the skin that affects patients of all ages andboth genders. The impact of the disease on quality of life is greater among patients with moderate to severe psoriasis.

OBJECTIVE

to establish a correlation between the psoriasis area and severity index (PASI) and theDermatology Life Quality Index (DLQI) based on a quality of life questionnaire adapted to the Brazilian contextfor patients with plaque psoriasis before and after systemic treatment.

METHODS

This was a cross-sectional, descriptive study of psoriasis patients who did not undergo treatment or who manifested clinical activity of the disease. Patients were evaluated according to the PASI and the quality of life questionnaire adapted to theBrazilian context before and 60 days after systemic treatment.

RESULTS

Thirty-five patients participated in thestudy. Twenty-six were men, with a mean age of 46 years. There was no correlation between the PASI and thequality of life questionnaire adapted to the Brazilian context, but there was a correlation between the PASI andsome items of the quality of life questionnaire adapted to the Brazilian context, such as jobs involving public contact.

CONCLUSION

The non-correlation between the PASI and the quality of life questionnaire adapted to the Brazilian context in this work may be associated with a history of chronic disease, which implies greater acceptance of the illness, or may be related to the low income and social status of the patients studied. The correlationobserved among patients with careers involving public contact suggests that some professions are more impacted by the disease. It may be necessary to adapt the quality of life questionnaire to patients with a low income andcultural and social limitations. The small sample size (n=35 patients) and the short follow-up period of 60 dayswere some of the limitations of this work.

Paracoccidioidomycosis: epidemiological, clinical, diagnostic and treatment up-dating

Paracoccidioidomycosis is an acute - to chronic systemic mycosis caused by fungi of the genus Paracoccidioides. Due to its frequent tegument clinical expression, paracoccidioidomycosis is an important disease for dermatologists, who must be up-to-date about it. This article focuses on recent epidemiological data and discusses the new insights coming from molecular studies, as well as those related to clinical, diagnostic and therapeutic aspects. In the latter section, we give particular attention to the guideline on paracoccidioidomycosis organized by specialists in this subject.

Chronic graft-versus-host disease: clinical presentation of multiple lesions of lichenoid and atrophic pattern

Graft-versus-host disease is observed mainly in recipients of hematopoietic cell transplantation and is expressed by cutaneous or systemic signals and symptoms. Graft-versus-host disease is clinically classified as acute or chronic. Chronic Graft-versus-host disease occurs in up to 70% of hematopoietic cell transplanted patients and its clinical manifestations have important impact on morbidity and quality of life. The authors report an expressive cutaneous, oral and adnexal involvement in a patient with chronic Graft-versus-host disease with multiple lesions of lichenoid and atrophic pattern.

Paracoccidioidomycosis of external genitalia: report of six new cases and review of the literature

BACKGROUND

Paracoccidioidomycosis is a systemic mycosis of dermatological interest due to the frequency of cutaneous and mucosal lesions. The involvement of the external genitalia is extremely rare and few cases have been reported.

OBJECTIVE

To study the prevalence of external genitalia lesions in paracoccidioidomycosis patients, identify clinical characteristics and compare with what is observed in the specific literature.

METHODS

This is a cross-sectional, descriptive study, with focus on paracoccidioiodomycosis patients with external genitalia lesions. The demographic and clinical aspects of cases were compared with what has been reported so far on LILACS, SciELO e MEDLINE data bases.

RESULTS

Data of 483 cases of paracoccidioidomycosis were studied in a 42-year period. Six (1.2%) patients showed specific lesions on external genitalia. Five patients were male with mean age of 47.2 years and all of them presented with the chronic multifocal clinical form. Only one, a 15-year-old female patient was observed who showed a subacute clinical form, juvenile type.

CONCLUSION

Compromise of the genitourinary tract among paracoccidioidomycosis patients is rare and even rarer when only the external genitalia are considered. As observed in the classical picture of paracoccidioidomycosis patients, the male gender and the chronic multifocal clinical form prevailed in the present study.

Trichobacteriosis: case report and dermoscopic study

The authors report a case of axillary trichobacteriosis in a 16 year-old patient whose complaints were bromhidrosis and hyperhidrosis axillaris. Although it can be diagnosed clinically, dermoscopy may be useful in some cases and reveal remarkable academic images.

Mycosis fungoides and Sézary syndrome: clinical, histopathological and immunohistochemical review and update

This paper reviews the diagnostic and classificatory concepts of mycosis fungoides and Sézary syndrome in light of the latest normative publications. It describes the great variability of the clinical expression of mycosis fungoides in its early stages as well as the histopathological and immunohistochemical aspects that help with diagnosis. The diagnostic criteria required for characterizing Sézary syndrome and the staging system used for both mycosis fungoides and Sézary syndrome are described.

White piedra and pediculosis capitis in the same patient

White piedra is a superficial mycosis caused by the genus Trichosporon. It is characterized by nodules on the hair shaft. Pediculosis capitis is caused by Pediculus humanus var. capitis of the suborder Anoplura. Whereas pediculosis is a common infestation, clinical reports of white piedra are rare. Molecular biology procedures identified T. inkin as the agent of white piedra in this case report. The authors present associations between the two diseases in the same patient in order to highlight their clinical differences.

White piedra: molecular identification of Trichosporon inkin in members of the same family

INTRODUCTION: White piedra is a superficial mycosis caused by the genus Trichosporon and characterized by nodules on hair shaft. METHODS: The authors report a family referred to as pediculosis. Mycological culture on Mycosel® plus molecular identification was performed to precisely identify the etiology. RESULTS: A Trichosporon spp. infection was revealed. The molecular procedure identified the agent as Trichosporon inkin. CONCLUSIONS: White piedra and infection caused by T. inkin are rarely reported in Southern Brazil. The molecular tools are essentials on identifying the Trichosporon species.

Exuberant clinical presentation of probable Malassezia folliculitis in a young nonimmunosuppressed patient

Malassezia folliculitis is an inflammatory disorder observed in both immunocompetent and immunosuppressed patients. The authors describe an unusual and exuberant presumed case affecting the face, trunk and upper limbs of a 12-year-old nonimmunosuppressed patient. Although the agent was not identified by culture, the clinical and histopathological aspects plus the response to specific treatment support the diagnosis of Malassezia folliculitis. The only possible predisponent cause observed on the patient was greasy skin. Repetitive cultures were negative. Treatment with itraconazol promoted apparent cure, however, the patient relapsed twelve months later.

Paracoccidioidomycosis in a patient with cervical cancer

This report describes the case of a female patient with paracoccidioidomycosis associated with a stage IIIB cervical carcinoma. Paracoccidioidomycosis in association with a malignant tumor occurs in 0.16% to 14.1% of cases in accordance with different case series. In cases in which the cancer is disseminated, the fungal infection may behave opportunistically.

Actinic cheilitis and squamous cell carcinoma of the lip: clinical, histopathological and immunogenetic aspects

Actinic cheilitis is the main precancerous lesion of the lip. Squamous cell carcinoma of the lip is reported together with oral carcinomas in the Brazilian official statistics. Overall, they account for 40% of the head and neck carcinomas. In general, physicians and dentists know little about what causes oral tumor development and progression. Tumor suppressor genes and cell proliferation regulatory proteins play a role in the progression of actinic cheilitis to squamous cell carcinoma and in its biological behavior. Knowledge on prognostic and diagnostic markers has a positive impact on the follow-up of these patients.

Fungal infections of the mucous membrane

A clinical review of three potentially severe fungal diseases, which are characterized in many cases by mucosal involvement, is presented. They are paracoccidioidomycosis, histoplasmosis, and mucormycosis. Mucosal involvement for paracoccidioidomycosis and rhinocerebral mucormycosis is frequent. Thus, oral involvement may provide early clue for diagnosis. In paracoccidioidomycosis, the mucosal lesion classically shows superficial ulcers with granular appearance and hemorrhagic points, usually on lips, palate, and jugal mucosa. In mucormycosis, necrosis of the palate followed for purulent discharge is a hallmark of rhinocerebral disease. Treatment with amphotericin B desoxycholate or the new second-generation triazoles is highly efficacious.