Hypopigmented white patches in a newborn

A newborn developed multiple hyperkeratotic erythematous papules, some with central erosions, mainly located on her scalp and trunk. Histopathology revealed a dense infiltrate of monotonous mononuclear cells with pale pink cytoplasm and reniform nuclei, positive for CD1a, S100 protein and langerin.

Drug-induced accelerated nodulosis: review of the literature

Accelerated nodulosis, the rapid progression/extension of preexisting nodules, is a recognized complication of immunomodulatory therapy, occurring mostly in patients with rheumatoid arthritis treated with methotrexate. As of today, its physiopathology remains incompletely understood, and there are no standardized guidelines regarding its management. Here, we conduct a literature review of the reported cases of drug-induced accelerated nodulosis and add our case of a 79-year-old female with an atypical clinical presentation.

Deep dermatophytosis caused by Trichophyton rubrum in immunocompromised patients

In immunosuppressed patients, dermatophytosis can be more invasive, affecting the dermis and subcutaneous tissues. The authors describe the cases of two patients with kidney and heart transplanted, respectively, that developed a deep dermatophytosis caused by Trichophyton rubrum, confirmed by culture and DNA sequencing. Both patients had concomitant onychomycosis, and both were treated with itraconazole for about two months, which was interrupted due to pharmacological interactions with the immunosuppressive drugs and switched to terbinafine, leading to clinical resolution within four months. Deep dermatophytosis should be considered when dealing with immunocompromised patients, especially when a superficial dermatophytosis is present. Oral treatment is necessary and terbinafine is a preferable option in solid organ transplant recipients because it has less pharmacological interactions.

Cutaneous Rosai-Dorfman disease: a challenging diagnosis

Rosai-Dorfman disease is a rare benign histiocytic proliferative disease of unknown cause that, in exceptional cases, presents with lesions confined to the skin. Clinically variable types of lesions such as papules, nodules and plaques have been reported. We present a case of a 27-year-old woman with a 1-year history of erythematous papular and nodular lesions on the malar and right axillary regions, previously misdiagnosed as acne. She reported no fever, malaise or weight loss, while physical examination and laboratory workup were normal. Bacteriological and mycobacteriological cultures were negative. Histopathological findings showed dense infiltration of inflammatory cells involving the entire dermis, consisting of large macrophages with emperipolesis, S100 and CD68 positive, neutrophils, eosinophils, lymphocytes and plasma cells. The patient was treated with oral prednisolone without improvement. Dapsone was subsequently initiated with favourable clinical response. The present article aimed to emphasise the clinical and histological differential diagnosis and share the treatment experience.

6 Years’ Experience of Mohs Micrographic Surgery in a Portuguese Hospital

Introduction: Mohs micrographic surgery (MMS) is a surgical method of treating skin tumors that consists of histological control of the tumor margins using horizontal slices in thin, freshly frozen layers. This technique is a preferred indication for cutaneous facial tumors (basal and squamous cell carcinoma, among others) associated with higher risk of recurrence, recurrent tumors, tumors with undefined clinical margins, when there is perivascular and perineural involvement or with aggressive histological subtypes. Methods: The authors carried out a retrospective study of a 6-year period (from July 2012 until June 2018) at a Portuguese hospital – Egas Moniz hospital, to define the characteristics of patients undergoing Mohs micrographic surgery and to evaluate the advantages of this technique. The following factors were analyzed: age, gender, provenience, diagnosis, tumor location, number of stages of MMS, type of reconstruction of the surgical defect, follow-up and recurrences. Results: A total of 835 tumors were excised, 459 in male patients and 376 in female patients. The mean age at surgery was 71 years old (range 23- 95 years). Most of the lesions submitted to MMS were basal cell carcinomas (87%) and the most common location was the nasal pyramid (43%). In 44% of the cases, it was necessary to perform more than one micrographic stage. Half of the surgical defect closures were performed by graft or skin flap. Considering patients with a follow up equal or superior to 3 years, the recurrence rate was 4.9%. Discussion: The most frequent diagnosis was basal cell carcinoma, reflecting the importance of MMS in this type of skin malignancy, in both primary and persistent/recurrent lesions. Compared to other European surgery reviews, our recurrence rate is within normal range. This fact is particularly relevant, if we consider that our institution receives patients sent from hospitals and dermatologists from all over the country, specially selected for tumor aggressiveness or previous relapse. More than half of these patients were referred from other centers and consisted of persistent/recurrent basal cell carcinomas. The follow-up at recurrence for MMS was 27.9 months, supporting that a long follow-up of these patients is necessary. Conclusion: MMS allows lower rates of recurrence compared to simple surgical excision, so its practice should be encouraged in selected tumors. The surgical control of the margins instead of the “blind margins” is an advantage in saving healthy tissue and allows the complete excision of the tumor in the same surgical time.

Pediatric Kaposi's sarcoma associated with immune reconstitution inflammatory syndrome

Immune reconstitution inflammatory syndrome (IRIS) represents paradoxical immune-mediated inflammation in response to an infecting pathogen, occurring after initiation of antiretroviral therapy (ART), concomitantly with immune system recovery. It has also been described in Kaposi's sarcoma (KS). We report a case of a 9-year-old Guinean girl, who developed Kaposi's sarcoma, following introduction of ART. KS associated with immune reconstitution inflammatory syndrome is rare, especially in children, but with the increased use of ART is becoming more prevalent.

Giant fibrous hamartoma of infancy: pitfall of CD34 positive dermal mesenchymal tumor

Fibrous hamartoma of infancy (FHI) is a rare benign soft tissue tumor with a triphasic organoid histologic appearance. The authors present a case of a 21-month-old healthy girl with a slowly growing flesh-colored subcutaneous plaque 12cm in size on the lower back, with overlying hypertrichosis. A punch biopsy revealed a proliferation of spindle cells infiltrating the dermis and hypodermis organized in a dense storiform pattern with a strong diffuse positivity for CD34. The diagnosis of congenital dermatofibrosarcoma protuberans (DFSP) was considered and an excision was performed. Histopathologic analysis showed an extensive poorly demarcated mass infiltrating the dermis and hypodermis, composed of different components: a monomorphous fibroblastic/myofibroblastic component, a mature adipose component, and an immature mesenchymal basophilic component. The clinical aspects with the histologic and immunohistochemical features led to the diagnosis of giant fibrous hamartoma of infancy. In our case the strong diffuse CD34 positivity was a diagnostic pitfall leading to an incorrect hypothesis of congenital DFSP. The characteristic triphasic histology of FHI was missed owing to the small size of the punch biopsy. This article highlights the importance of being aware of the CD34+ dermal mesenchymal tumor differential diagnosis and the necessity of appropriate size biopsies to avoid sampling error.

Cutaneous complication of perinatal hypoxia

Subcutaneous fat necrosis of the newborn is an uncommon, transient, and self-healing panniculitis, mostly affecting term newborns with perinatal complications. The authors present a case of a female full-term neonate, born from an uncomplicated pregnancy, admitted into the neonatology unit 5 hours after delivery because of refractory multifocal seizures in the context of hypoxic-ischemic encephalopathy. Nine days after birth, indurated and erythematous nodules and plaques were noted on the left arm and back. Skin biopsy was compatible with subcutaneous fat necrosis of the newborn. Laboratory evaluation including serum calcium showed normal values. No treatment was initiated. This entity generally follows an uncomplicated course. However, there are important complications for which the patient must be regularly monitored, including thrombocytopenia, hypoglycemia, hypertriglyceridemia, and most importantly, hypercalcemia. Patients should have serial serum calcium determinations for up to 6 months after the appearance of the skin lesions. The early diagnosis and prompt treatment of hypercalcemia are essential to prevent severe complications.

Formação, trabalho e competências transversais – a importância da formação profissional

O presente artigo aborda um estudo de caso realizado no Hospital de Braga, com focus na formação “Cuidar Mais”. O estudo revela a importância das competências transversais no interface formação e trabalho e destaca a comunicação e o relacionamento interpessoal como competências atrativas ao mercado de trabalho. As competências transversais na formação profissional enfatizam a sua preponderância, seja na mobilidade para o trabalho, seja na manutenção do mesmo. A investigação revela, ainda, o potencial transformador da formação profissional, sendo para isso necessário construi-la com base em quatro pilares: i) relevância; ii) justiça; iii) democracia; iv) motivação.

Currículo e formação inicial em Educação Física: uma reflexão preliminar

Esta proposta apresenta uma reflexão sobre o projeto pedagógico do curso de Educação Física do Instituto Federal do Ceará campus Juazeiro do Norte. É parte de uma pesquisa de Doutorado em Ciências da Educação – Universidade do Minho. Parte da questão: com base no currículo oficial, como o processo de decisão curricular do curso de Educação Física é caracterizado pelo IFCE? Realizou-se uma análise documental do projeto pedagógico do referido curso e da Resolução Nº 2/2015 do Conselho Nacional de Educação. 

Cutaneous collagenous vasculopathy: a rare cause of generalised cutaneous telangiectasia

Cutaneous collagenous vasculopathy is a rare cutaneous microangiopathy of unknown aetiology with only 27 cases reported to date. It is characterised clinically by generalised cutaneous telangiectasias and microscopically by dilation and marked thickening of the walls of superficial dermal blood vessels. Differential diagnosis should be performed with other causes of disseminated telangiectasias, including generalised essential telangiectasia, from which it is clinically indistinguishable. We report a new case of cutaneous collagenous vasculopathy in a 61-year-old woman presenting with a 5-year history of asymptomatic telangiectasias distributed symmetrically on her upper and lower limbs and highlight the importance of clinicopathological correlation for the diagnosis of this disease.

Brown plaques on the lower back

A 12-year-old girl presented with a 2-year history of a 10 cm area of asymptomatic brown coalescent plaques of coalescent, linearly arranged papules on the lower back. No other physical or systemic abnormality was detected. Routine laboratory investigations, including thyroid function tests, were normal. The histopathological examination revealed hyperkeratosis, papillomatosis, and elongated rete ridges in the epidermis. On special staining (Alcian blue), mucin deposition was seen in the papillary dermis. The remaining dermis was normal. A diagnosis of Mucinous Nevus was made.

Lupus miliaris disseminatus faciei: a case report

A 33-year-old man presented to our clinic with asymptomatic red-brown, dome-shaped papules, distributed bilaterally on the central area of the face (forehead, lower portions of the eyelids, nasolabial folds, and perioral areas) these had evolved over a period of about 1 year. A skin biopsy, taken from a lesion on the forehead, revealed an epithelioid cell granuloma with central necrosis and surrounding lymphocytic infiltrate with multinucleate giant cells. The chest X-ray and the results of the laboratory studies were within normal limits; the Mantoux test was negative. The patient was treated with minocycline 100 mg/day for 4 months. There was significant clinical improvement, but papular lesions remained on the forehead. Later on, treatment with systemic steroids for 7 months resulted in the resolution of most lesions.

COMMENT

Lupus miliaris disseminatus faciei (LMDF) is an uncommon, chronic, inflammatory dermatosis characterized by red-to-yellow or yellow-brown papules of the central face, particularly on and around the eyelids. Originally, LMDF was considered to be a variant of lupus vulgaris or a tuberculid because of the histology, but there has been no evidence to date supporting a link to tuberculosis. Some authors consider LMDF to be a granulomatous forms of rosacea. However, our case supports the concept that it is a distinct entity.

Lyme borreliosis in Portugal caused by Borrelia lusitaniae? Clinical report on the first patient with a positive skin isolate

BACKGROUND

Borrelia lusitaniae was isolated from an Ixodes ricinus tick in Portugal in 1993 for the first time. Further, this borrelia genospecies has been found in ixodid ticks collected around the coasts of southern Portugal and North Africa. Its reservoir has not been defined yet. B. lusitaniae was isolated once until now from a patient with a long standing and expanding skin disorder.

PATIENT AND METHODS

A 46-year-old Portuguese woman presented with a skin lesion on the left thigh which had evolved slowly over ten years. The patient reported limb paraesthesias, cramps, chronic headaches, and cardiac rhythm disturbances. History of tick bites was negative nor had the patient ever noticed a skin lesion comparable with erythema chronicum migrans. Skin biopsies were taken for histological evaluation, culture and DNA detection. Antibodies to borrelia were searched by indirect immunofluorescence assay and Western-blot.

RESULTS

A bilateral carpal tunnel syndrome and local synovitis was diagnosed. Dermato-histology was normal, serology was negative. Spirochaetal organisms were cultured from a skin biopsy and identified as B. lusitaniae. The patient improved after a 2-week course of intravenous ceftriaxone; the skin lesions did not expand further.

CONCLUSIONS

This culture confirmed skin infection by B. lusitaniae in a patient from Portugal suggests an additional human pathogen out of the B. burgdorferi sensu lato complex in Europe, particularly in Portugal.

Dermatofibrosarcoma protuberans: a clinicopathological study of 20 cases

AIM

To review the dinical and histological data of 20 cases of dermatofibrosarcoma protuberans presenting at two dermatology centres in Lisbon from 1978 to 1998.

PATIENTS AND METHODS

The 20 subjects comprised nine males and 11 females ranging in age from 25 to 79 years, with highest frequency of subjects in the 30-50 year olds. We reviewed the clinical features, histopathological aspects, including morphologic variants and immunohistochemical studies.

RESULTS

Median age at diagnosis was 51 years and the trunk was the most frequent location. The characteristic histologic storiform pattern was seen in all cases. Three subjects presented fibrosarcomatous areas, one with myoid differentiation and another with multinucleated giant cells. Immunohistochemical stains revealed CD34 expression in the 18 specimens tested, FXIIIa was negative, and these two antigens proved important for the differential diagnosis of this neoplasm. Local wide excision was performed in 13 cases and seven patients underwent Moh's micrographic surgery. Follow-up ranged from 2 months to 17 years and three recurrences were recorded, two following classical surgery and one after Moh's surgery; there was no difference in the rate of local recurrence (15%) for the two kinds of treatment in our series.