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Santos LSD, Drummond MR, Goulart IMB, França AFEDC, Souza EMD, Ferreira Velho PEN. Bartonella henselae as a putative trigger for chronic type 2 leprosy reactions. Braz J Infect Dis 2023; 27:103701. [PMID: 37980941 PMCID: PMC10709108 DOI: 10.1016/j.bjid.2023.103701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/20/2023] [Accepted: 10/31/2023] [Indexed: 11/21/2023] Open
Abstract
Leprosy reactions are an acute inflammatory phenomenon that can arise before diagnosis, during treatment, or after cure of leprosy. These reactions are considered one of the main diseases that cause physical disabilities. Immunosuppressive treatment for these immune responses makes these patients susceptible to coinfections, which can trigger new leprosy reactions. The main objective of this study was to evaluate the occurrence of infection by Bartonella sp. in blood samples from 47 patients who had untreatable episodes of type 2 leprosy reactions for more than six months, comparing them with a control group. Cultures and molecular methods (PCR) were used. Amplicons from species-specific reactions and sequencing showed a higher prevalence of Bartonella henselae infection in patients, 19/47 (40.4 %), compared to control, 9/50 (18.0 %), p = 0.0149. Five patients accepted treatment for coinfection, and all showed improvement in leprosy reactions with treatment for B. henselae infection. We conclude that these bacteria can trigger chronic reactions of type 2 leprosy and should be investigated in these patients. SUMMARY LINE: Patients who have chronic type 2 leprosy reactions are more susceptible to Bartonella henselae infection than controls: 19/47 (40.4 %) compared 9/50 (18.0 %), p = 0.0149.
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Affiliation(s)
- Luciene Silva Dos Santos
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Laboratório de Pesquisa Aplicada em Dermatologia e Infecção por Bartonella, Campinas, SP, Brazil.
| | - Marina Rovani Drummond
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Laboratório de Pesquisa Aplicada em Dermatologia e Infecção por Bartonella, Campinas, SP, Brazil
| | - Isabela Maria Bernardes Goulart
- Universidade Federal de Uberlândia, Centro Nacional de Referência em Dermatologia Sanitária e Hanseníase, Uberlândia, MG, Brazil
| | | | - Elemir Macedo de Souza
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Medicina, Divisão de Dermatologia, Campinas, SP, Brazil
| | - Paulo Eduardo Neves Ferreira Velho
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Laboratório de Pesquisa Aplicada em Dermatologia e Infecção por Bartonella, Campinas, SP, Brazil; Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Medicina, Divisão de Dermatologia, Campinas, SP, Brazil
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Drummond MR, Dos Santos LS, de Almeida AR, Lins KDA, Barjas-Castro ML, Diniz PPVDP, Velho PENF. Comparison of molecular methods for Bartonella henselae detection in blood donors. PLoS Negl Trop Dis 2023; 17:e0011336. [PMID: 37262044 DOI: 10.1371/journal.pntd.0011336] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 04/25/2023] [Indexed: 06/03/2023] Open
Abstract
The Bartonella genus consists of neglected pathogens associated with potentially transfusional-transmitted and fatal human diseases. We aimed to evaluate Bartonella sp. prevalence in 500 blood donors and compare the results with the data already published about these samples. We used molecular diagnostic methods to detect Bartonella sp.-DNA from blood and liquid culture samples: (A) conventional PCR for two gene regions, the ITS targeting the genus Bartonella and the specific gltA Bartonella henselae; (B) nested PCR for the ftsZ gene and (C) qualitative real-time PCR for the gltA gene, both B. henselae specific. We obtained 30/500 (6%) DNA detections from the blood samples; 77/500 (15.4%) DNA detections from liquid culture samples and five (1%) samples had DNA detection from both. In total, we detected B. henselae DNA from 102/500 (20.4%) donors. The samples used in this study had already been submitted for Bartonella sp.-DNA detection using only a conventional PCR in liquid culture. Sixteen samples (3.2%) were positive previously, and from these 16 samples, 13 were negative in the new investigation. We concluded that the use of liquid culture combined with different molecular tests increases the possibility of detecting Bartonella sp.-DNA, but the tests do not avoid false-negative results. More than a fifth of blood donors had at least one PCR that detected Bartonella sp.-DNA among the eight molecular reactions performed now (four reactions in whole blood and four in liquid culture). Seven percent had B. henselae-DNA detection for two or more distinct regions. Considering the results obtained previously, the DNA of Bartonella spp. was detected or the agent isolated in 23% of analyzed blood donors. The results establish that the low bacteremia and the fastidious characteristics of the bacterium are challenges to laboratory diagnosis and can make it difficult to confirm the infection in patients with bartonelloses.
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Affiliation(s)
- Marina Rovani Drummond
- Applied Research in Dermatology and Bartonella Infection Laboratory, University of Campinas-UNICAMP; Campinas, Sao Paulo, Brazil
| | - Luciene Silva Dos Santos
- Applied Research in Dermatology and Bartonella Infection Laboratory, University of Campinas-UNICAMP; Campinas, Sao Paulo, Brazil
| | - Amanda Roberta de Almeida
- Applied Research in Dermatology and Bartonella Infection Laboratory, University of Campinas-UNICAMP; Campinas, Sao Paulo, Brazil
| | - Karina de Almeida Lins
- Applied Research in Dermatology and Bartonella Infection Laboratory, University of Campinas-UNICAMP; Campinas, Sao Paulo, Brazil
| | | | | | - Paulo Eduardo Neves Ferreira Velho
- Applied Research in Dermatology and Bartonella Infection Laboratory, University of Campinas-UNICAMP; Campinas, Sao Paulo, Brazil
- Division of Dermatology, Department of Medicine, UNICAMP, Campinas, Sao Paulo, Brazil
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Drummond MR, Santos LSD, Souza LB, Mitsuushi GN, Cintra ML, França AFEDC, Souza EMD, Velho PENF. Detection of Bartonella henselae DNA in the blood of patients with livedoid vasculopathy. An Bras Dermatol 2023:S0365-0596(23)00066-1. [PMID: 36973097 DOI: 10.1016/j.abd.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/18/2022] [Accepted: 07/21/2022] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Livedoid vasculopathy (LV) manifests as ulcers and atrophic white scars on the lower extremities. The main known etiopathogenesis is hypercoagulability with thrombus formation, followed by inflammation. Thrombophilia, collagen and myeloproliferative diseases may induce LV, but the idiopathic (primary) form predominates. Bartonella sp. may cause intra-endothelial infection and skin manifestations caused by these bacteria may be diverse, including leukocytoclastic vasculitis and ulcers. OBJECTIVE The aim of this study was to investigate the presence of bacteremia by Bartonella spp. in patients with difficult-to-control chronic ulcers diagnosed as primary LV. METHODS Questionnaires and molecular tests (conventional PCR, nested PCR and real-time PCR) were applied and liquid and solid cultures were performed in the blood samples and blood clot of 16 LV patients and 32 healthy volunteers. RESULTS Bartonella henselae DNA was detected in 25% of LV patients and in 12.5% of control subjects but failed to reach statistically significant differences (p = 0.413). STUDY LIMITATIONS Due to the rarity of primary LV, the number of patients studied was small and there was greater exposure of the control group to risk factors for Bartonella spp. INFECTION CONCLUSION Although there was no statistically significant difference between the groups, the DNA of B. henselae was detected in one of every four patients, which reinforces the need to investigate Bartonella spp. in patients with primary LV.
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Affiliation(s)
- Marina Rovani Drummond
- Department of Clinical Medicine, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, São Paulo, SP, Brazil; Laboratory of Applied Research in Dermatology and Bartonella Infection, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, São Paulo, SP, Brazil.
| | - Luciene Silva Dos Santos
- Department of Clinical Medicine, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, São Paulo, SP, Brazil; Laboratory of Applied Research in Dermatology and Bartonella Infection, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, São Paulo, SP, Brazil
| | - Lais Bomediano Souza
- Department of Medicine, Pontifícia Universidade Católica de Campinas, Campinas, São Paulo, SP, Brazil
| | - Gabriela Nero Mitsuushi
- Department of Clinical Medicine, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, São Paulo, SP, Brazil
| | - Maria Letícia Cintra
- Department of Pathological Anatomy, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, São Paulo, SP, Brazil
| | | | - Elemir Macedo de Souza
- Department of Clinical Medicine, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, São Paulo, SP, Brazil
| | - Paulo Eduardo Neves Ferreira Velho
- Department of Clinical Medicine, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, São Paulo, SP, Brazil; Laboratory of Applied Research in Dermatology and Bartonella Infection, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, São Paulo, SP, Brazil
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Drummond MR, dos Santos LS, Fávaro RS, Stucchi RSB, Boin IDFSF, Velho PENF. Cryptogenic hepatitis patients have a higher Bartonella sp.-DNA detection in blood and skin samples than patients with non-viral hepatitis of known cause. PLoS Negl Trop Dis 2022; 16:e0010603. [PMID: 35849566 PMCID: PMC9292087 DOI: 10.1371/journal.pntd.0010603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 06/23/2022] [Indexed: 11/21/2022] Open
Abstract
Background This study aimed to assess the prevalence of Bartonella sp.-DNA detection in blood and skin samples from patients with non-viral end-stage liver disease awaiting liver transplantation. Methodology/Principal findings Blood samples and healthy skin fragments from 50 patients were tested using microbiological and molecular methods. Fifteen patients had cryptogenic hepatitis (CH) and 35 had alcoholic, drug-induced or autoimmune liver disease. DNA was extracted from whole blood and liquid culture samples, isolates, and skin fragments. Thirteen of the 50 patients (26%) had Bartonella henselae DNA detection in their blood (9/50) and/or skin (5/50) samples. Colonies were isolated in 3/50 (6%) and infection was detected in 7/50 (14%) of the 50 patients. B. henselae-DNA detection was more prevalent in patients with CH than in other patients (p = 0.040). Of 39 patients followed-up for at least two years, a higher mortality rate was observed among patients with CH infected with B. henselae (p = 0.039). Conclusions/Significance Further studies assessing the role of B. henselae infection in the pathogenesis of hepatitis patients must be urgently conducted. One in four patients with end-stage liver disease awaiting liver transplantation for hepatitis of non-viral origin had documented B. henselae-DNA detection and cryptogenic hepatitis patients have a higher bacterium molecular detection than patients with non-viral hepatitis of known cause.
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Affiliation(s)
- Marina Rovani Drummond
- Applied Research in Dermatology and Bartonella Infection Laboratory, University of Campinas, UNICAMP, Campinas, São Paulo, Brazil
| | - Luciene Silva dos Santos
- Applied Research in Dermatology and Bartonella Infection Laboratory, University of Campinas, UNICAMP, Campinas, São Paulo, Brazil
| | | | | | | | - Paulo Eduardo Neves Ferreira Velho
- Applied Research in Dermatology and Bartonella Infection Laboratory, University of Campinas, UNICAMP, Campinas, São Paulo, Brazil
- Division of Dermatology, Department of Medicine, UNICAMP, Campinas, São Paulo, Brazil
- * E-mail:
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Drummond MR, Visentainer L, Almeida ARD, Angerami RN, Aoki FH, Velho PENF. Bartonella henselae bacteremia diagnosed post-mortem in a myelodysplastic syndrome patient. Rev Inst Med Trop Sao Paulo 2019; 61:e50. [PMID: 31531628 PMCID: PMC6746197 DOI: 10.1590/s1678-9946201961050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 07/02/2019] [Indexed: 11/22/2022] Open
Abstract
This study involves a 49-year-old male, who for three years suffered with a myelodysplastic syndrome and who needed frequent blood transfusions. One day following a transfusion, he presented fever and abdominal pain. The fever became persistent and only improved temporarily with two cycles of intravenous ciprofloxacin. Nearly 120 days after beginning the second cycle of treatment, he had experienced a weight loss of 16 kg and recurring fever. Screening for fever of unknown origin was conducted, including Bartonella infection. No etiology could be found. The patient improved with an antimicrobial regimen composed of oral doxycycline and intravenous ciprofloxacin. After 15 days afebrile, the patient was discharged with a four-month oral prescription of doxycycline and ciprofloxacin. Eight months following the antibiotic treatment, the patient received an allogeneic bone marrow transplant. Five days following the transplant, the patient initiated a febrile neutropenia and died. From a blood sample collected and stored at the time of hospitalization, a microbiological and molecular study was performed again. Blood- and liquid culture-PCRs from the same blood sample were all negative, but an isolate from solid subculture was found. The molecular reactions from this isolate were all positive and the sequence was 100% homologous to Bartonella henselae . The present report points to the limitations of laboratory techniques currently available for investigation of possible cases of bartonellosis in clinical practice, and the potential risk of Bartonella spp. transmission through blood transfusions.
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Affiliation(s)
- Marina Rovani Drummond
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Campinas, São Paulo, Brazil
| | - Lorena Visentainer
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Campinas, São Paulo, Brazil
| | | | | | - Francisco Hideo Aoki
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Campinas, São Paulo, Brazil
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Improvement of Bartonella henselae DNA Detection in Cat Blood Samples by Combining Molecular and Culture Methods. J Clin Microbiol 2018. [PMID: 29540455 DOI: 10.1128/jcm.01732-17] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Bartonella spp. are bacteria of worldwide distribution that cause asymptomatic to fatal infections in animals and humans. The most common zoonotic species is Bartonella henselae, for which cats are the major natural reservoir host. To better understand Bartonella sp. diagnostic limitations, we determined the frequency of bloodstream infection in 112 cats by comparing and combining the results of multiple conventional and nested PCRs from blood and liquid culture samples. Using liquid culture conventional PCR, Bartonella sp. DNA was amplified from 27.7% of samples (31/112) compared to 90.2% of samples (101/112) by combining nested PCR from blood and liquid culture, indicating that PCR testing of more than one type of sample provides better sensitivity than a standalone PCR and that bloodstream infection is very frequent among cats in southeastern Brazil. This study reinforces the need for multistep testing for Bartonella sp. infection to prevent false-negative diagnostic results, even in reservoir hosts such as cats that typically maintain higher bacteremia levels.
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Velho PENF, Bellomo-Brandão MÂ, Drummond MR, Magalhães RF, Hessel G, Barjas-Castro MDL, Escanhoela CAF, Del Negro GMB, Okay TS. Bartonella henselae AS A PUTATIVE CAUSE OF CONGENITAL CHOLESTASIS. Rev Inst Med Trop Sao Paulo 2017; 58:56. [PMID: 27410916 PMCID: PMC4964325 DOI: 10.1590/s1678-9946201658056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 02/26/2016] [Indexed: 05/29/2023] Open
Abstract
Severe anemia and cholestatic hepatitis are associated with bartonella infections. A putative vertical Bartonella henselae infection was defined on the basis of ultrastructural and molecular analyses in a three-year-old child with anemia, jaundice and hepatosplenomegaly since birth. Physicians should consider bartonellosis in patients with anemia and hepatitis of unknown origin.
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Affiliation(s)
| | | | - Marina Rovani Drummond
- University of Campinas (UNICAMP) Medical Science School, Department of Medicine, Campinas, SP, Brazil
| | - Renata Ferreira Magalhães
- University of Campinas (UNICAMP) Medical Science School, Department of Medicine, Campinas, SP, Brazil
| | - Gabriel Hessel
- University of Campinas (UNICAMP) Medical Science School, Department of Pediatrics, Campinas, SP, Brazil
| | | | | | - Gilda Maria Barbaro Del Negro
- University of Sao Paulo (USP), School of Medicine and Institute of Tropical Medicine, Clinical Hospital, Division of Clinical Dermatology, Laboratory of Medical Mycology (LIM-53). Sao Paulo, SP, Brazil
| | - Thelma Suely Okay
- University of Sao Paulo (USP), Institute of Tropical Medicine, Laboratory of Seroepidemiology and Immunobiology. Sao Paulo, SP, Brazil
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da Silva MN, Vieira-Damiani G, Ericson ME, Gupta K, de Almeida AR, Drummond MR, Soares TCB, Lania BG, Gilioli R, Velho PENF. Acute and Late Bartonella henselae Murine Model Infection. Vector Borne Zoonotic Dis 2017; 17:206-208. [PMID: 28165916 DOI: 10.1089/vbz.2016.2007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Bartonella spp. are fastidious gram-negative neglected bacilli with worldwide distribution. They are able to cause intraerythrocytic and potentially fatal infection. Cats and dogs are reservoirs of some species of these agents. Blood-sucking arthropods are potential vectors. Our aim was to evaluate the blood, skin, liver, and spleen in BALB/c mice by using molecular tests and confocal microscopy to demonstrate Bartonella henselae infection in the bloodstream and organs after 4 and 21 days of intraperitoneally injected bacterial suspension. We demonstrate that the occurrence of infection in organs precedes the detectable infection in blood. Therefore, late manifestation in blood may be another challenge in early detection and diagnosis of B. henselae infection.
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Affiliation(s)
- Marilene Neves da Silva
- 1 Division of Dermatology, Department of Medicine, University of Campinas (UNICAMP) Medical School , Campinas, Brazil
| | - Gislaine Vieira-Damiani
- 1 Division of Dermatology, Department of Medicine, University of Campinas (UNICAMP) Medical School , Campinas, Brazil .,2 Federal Institute of Education , Science and Technology, São Paulo, Brazil
| | - Marna Elise Ericson
- 3 Department of Dermatology, University of Minnesota Medical School , Minneapolis, Minnesota
| | - Kalpna Gupta
- 4 Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical School , Minneapolis, Minnesota
| | - Amanda Roberta de Almeida
- 1 Division of Dermatology, Department of Medicine, University of Campinas (UNICAMP) Medical School , Campinas, Brazil
| | - Marina Rovani Drummond
- 1 Division of Dermatology, Department of Medicine, University of Campinas (UNICAMP) Medical School , Campinas, Brazil
| | - Tania Cristina Benetti Soares
- 1 Division of Dermatology, Department of Medicine, University of Campinas (UNICAMP) Medical School , Campinas, Brazil
| | - Bruno Grosselli Lania
- 1 Division of Dermatology, Department of Medicine, University of Campinas (UNICAMP) Medical School , Campinas, Brazil
| | - Rovilson Gilioli
- 5 Laboratory of Animal Quality Control, Multidisciplinary Center of Biological Investigation (CEMIB), University of Campinas (UNICAMP) , Campinas, Brazil
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Silva MN, Vieira-Damiani G, Ericson ME, Gupta K, Gilioli R, de Almeida AR, Drummond MR, Lania BG, de Almeida Lins K, Soares TCB, Velho PENF. Bartonella henselae transmission by blood transfusion in mice. Transfusion 2016; 56:1556-9. [PMID: 26968530 DOI: 10.1111/trf.13545] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 12/09/2015] [Accepted: 01/09/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Bartonella spp. are neglected fastidious Gram-negative bacilli. We isolated Bartonella henselae from 1.2% of 500 studied blood donors and demonstrated that the bacteria remain viable in red blood cell units after 35 days of experimental infection. Now, we aim to evaluate the possibility of B. henselae transmission by blood transfusion in a mouse model. STUDY DESIGN AND METHODS Eight BALB/c mice were intraperitoneal inoculated with a 30 µL of suspension with 10(4) CFU/mL of B. henselae and a second group of eight mice were inoculated with saline solution and used as control. After 96 hours of inoculation, the animals were euthanized. We collected blood and tissue samples from skin, liver, and spleen. Thirty microliters of blood from four Bartonella-inoculated animals were transfused into a new group (n = 4). Another group received blood from the control animals. B. henselae infection was investigated by conventional and nested polymerase chain reaction (PCR). RESULTS Blood samples from all 24 mice were negative by molecular tests though half of the tissue samples were positive by nested PCR in the intraperitoneal Bartonella-investigated animals. Tissues from two of the four mice that received blood transfusions from Bartonella-inoculated animals were also nested PCR positives. CONCLUSIONS Transmission of B. henselae by transfusion is possible in mice even when donor animals have undetectable bloodstream infection. The impact of human Bartonella sp. transmission through blood transfusion recipients must be evaluated.
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Affiliation(s)
- Marilene Neves Silva
- Division of Dermatology, Department of Medicine, University of Campinas (UNICAMP) Medical School, Campinas, SP, Brazil
| | - Gislaine Vieira-Damiani
- Division of Dermatology, Department of Medicine, University of Campinas (UNICAMP) Medical School, Campinas, SP, Brazil.,Federal Institute of Education, Science and Technology, Jaguariaiva, PR, Brazil
| | - Marna Elise Ericson
- Department of Dermatology, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Kalpna Gupta
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Rovilson Gilioli
- Laboratory of Animal Quality Control, Multidisciplinary Center of Biological Investigation (CEMIB), University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Amanda Roberta de Almeida
- Division of Dermatology, Department of Medicine, University of Campinas (UNICAMP) Medical School, Campinas, SP, Brazil
| | - Marina Rovani Drummond
- Division of Dermatology, Department of Medicine, University of Campinas (UNICAMP) Medical School, Campinas, SP, Brazil
| | - Bruno Grosselli Lania
- Division of Dermatology, Department of Medicine, University of Campinas (UNICAMP) Medical School, Campinas, SP, Brazil
| | - Karina de Almeida Lins
- Division of Dermatology, Department of Medicine, University of Campinas (UNICAMP) Medical School, Campinas, SP, Brazil
| | - Tânia Cristina Benetti Soares
- Division of Dermatology, Department of Medicine, University of Campinas (UNICAMP) Medical School, Campinas, SP, Brazil
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