Majocchi’s Granuloma by Trichophytum rubrum in a kidney transplant patient - A case report

Introduction: Trichophytum rubrum is a filamentous fungus, with worldwide distribution, that usually causes superficial infections of skin and nails, namely tinea pedis, tinea corporis, tinea cruris and onychomycosis. Rarely, severe dermatophytosis can occur, presenting as deep dermatophytosis, Majocchi’s Granuloma or extensive dermatophytosis. Objectives and Methods: Case report of Majocchi’s Granuloma in a kidney transplant patient. Results: A case of a 55-year-old woman who underwent a kidney transplant 7 months before, under immunosuppressive therapy with tacrolimus and mycophenolate mofetil. She attended a Dermatology consultation to clarify skin lesions that appeared 6 months earlier. The skin exam revealed hard and painful plaque lesions on both legs, with an ulcer on the left leg lesion, violaceous papular lesions on the dorsum of the left foot and toes and a hard consistency nodule on the left leg. Some of the toe nails presented dystrophy or onycholysis. The patient denied any previous trauma or contact with plants or soil. Biopsies of lesions of the left leg and foot dorsum where sent for histology and mycological culture and toe nails for mycological culture. The histological examinations showed, in the reticular dermis and reaching the hypodermis, suppurative granulomas with multinucleated giant cells and areas of necrosis. PAS (Periodic Acid- Schiff) and GMS (Grocott’s Methenamine Silver) staining revealed multiple spores and septate hypha within the granulomas but not in the stratum corneum. No remnants of hair follicles where found. Culture of skin biopsies were positive for Tricophytum rubrum but nails´ culture was negative. Identification was further confirmed by sequencing of ITS region of ribosomal DNA (GenBank accession number MK967277). Oral Itraconazole 100mg bid and topic Sertoconazole where initiated. The patient was observed one month after and reported general malaise, tiredness, exertional dyspnea, whitish stools and increased abdominal volume. The physician chose to discontinue itraconazole and initiate oral terbinafine 250mg id. After two months on oral terbinafine, there was regression of the legs´ and left foot lesions with ulcer healing and disappearance of the left leg nodule. Conclusion: Diagnosis of deeper dermatophytosis is difficult, in part because there is no specific clinical presentation and, in many cases, it is even polymorphic. However, especially in patients with immunodeficiency, this hypothesis should be weighed. Confirmation is achieved by finding hyphae compatible with dermatophytes in the dermis and a positive culture for a dermatophyte. Treatment should include systemic antifungal agents, to which topical medication may be associated. Multiple therapeutic regimens have been proposed, but randomized trials or large case series are lacking. Antifungal therapy should be continued until the lesions are completely resolved. Surgical treatment has been reported as an option for highly localized lesions.info:eu-repo/semantics/publishedVersio

Tumor regression grades: can they influence rectal cancer therapy decision tree?

BACKGROUND: Evaluating impact of tumor regression grade in prognosis of patients with locally advanced rectal cancer (LARC). MATERIALS AND METHODS: We identified from our colorectal cancer database 168 patients with LARC who received neoadjuvant therapy followed by complete mesorectum excision surgery between 2003 and 2011: 157 received 5-FU-based chemoradiation (CRT) and 11 short course RT. We excluded 29 patients, the remaining 139 were reassessed for disease recurrence and survival; the slides of surgical specimens were reviewed and classified according to Mandard tumor regression grades (TRG). We compared patients with good response (Mandard TRG1 or TRG2) versus patients with bad response (Mandard TRG3, TRG4, or TRG5). Outcomes evaluated were 5-year overall survival (OS), disease-free survival (DFS), local, distant and mixed recurrence. RESULTS: Mean age was 64.2 years, and median followup was 56 months. No statistically significant survival difference was found when comparing patients with Mandard TRG1 versus Mandard TRG2 (p = .77). Mandard good responders (TRG1 + 2) have significantly better OS and DFS than Mandard bad responders (TRG3 + 4 + 5) (OS p = .013; DFS p = .007). CONCLUSIONS: Mandard good responders had a favorable prognosis. Tumor response (TRG) to neoadjuvant chemoradiation should be taken into account when defining the optimal adjuvant chemotherapy regimen for patients with LAR

Perforated peptic ulcer: main factors of morbidity and mortality.

World J Surg. 2003 Jul;27(7):782-7. Perforated peptic ulcer: main factors of morbidity and mortality. Noguiera C, Silva AS, Santos JN, Silva AG, Ferreira J, Matos E, Vilaça H. Surgery Department, Surgery 1, Hospital Geral de Santo António, Instituto de Ciencias Biomédicas Abel Salazar, Largo do Prof. Abel Salazar, 4099-001 Oporto, Portugal. Abstract It is well stated in the literature that medical treatment for peptic ulcer is based on a combination of proton pump inhibitors (PPIs) and antibiotics to eradicate Helicobacter pylori. This treatment is associated with a high rate of immediate success and a low rate of recurrence at 12 months, although it is not effective in all patients. Peptic ulcer (PU) perforation is a serious problem that leads to high complication and mortality rates. Surgical treatment, with its various possibilities, constitutes the ideal treatment. Surgical intervention in these cases, however, can be directed to treating the perforation alone, or it can offer definitive treatment of the ulcer itself. With the hope of establishing why such complications and mortality were seen in the patients in our hospital population, we gathered the facts about PU perforations and the types of surgery performed. We studied 210 consecutive patients (150 men, 60 women) who had undergone surgery at our hospital because of perforation between January 1, 1990 and December 31, 2000. The patients' median age was 53.0 +/- 20.6 years (men 47.7 +/- 17.3 years; women 66.3 +/- 22.0 years). Altogether, 86 patients had significant associated illnesses, 62 were admitted more than 24 hours after the perforation, and 25 were admitted in shock. We performed resections in 10 patients; 88 patients were treated by suturing the perforation with or without a patch of epiploon; and 112 underwent a troncular vagotomy with drainage (VT + Dr). A total of 21 patients died (10%). Significant risk factors that led to complications were identified by statistical studies. They were a perforation that had been present more than 24 hours, the coexistence of significant associated illnesses, and resection surgery. The significant risk factors that led to death were the presence of shock at admission, the coexistence of significant illnesses, and resection surgery. There was no statistically significant difference concerning morbidity and mortality between simple closure of the perforation and definitive surgery (VT + Dr). PMID: 14509505 [PubMed - indexed for MEDLINE

Predictive Response Value of Pre- and Postchemoradiotherapy Variables in Rectal Cancer: An Analysis of Histological Data

Background. Neoadjuvant chemoradiotherapy (nCRT) followed by curative surgery in locally advanced rectal cancer (LARC) improves pelvic disease control. Survival improvement is achieved only if pathological response occurs. Mandard tumor regression grade (TRG) proved to be a valid system to measure nCRT response. Potential predictive factors for Mandard response are analyzed. Materials and Methods. 167 patients with LARC were treated with nCRT and curative surgery. Tumor biopsies and surgical specimens were reviewed and analyzed regarding mitotic count, necrosis, desmoplastic reaction, and inflammatory infiltration grade. Surgical specimens were classified according to Mandard TRG. The patients were divided as "good responders" (Mandard TRG1-2) and "bad responders" (Mandard TRG3-5). According to results from our previous data, good responders have better prognosis than bad responders. We examined predictive factors for Mandard response and performed statistical analysis. Results. In univariate analysis, distance from anal verge and ten other postoperative variables related with nCRT tumor response had predictive value for Mandard response. In multivariable analysis only mitotic count, necrosis, and differentiation grade in surgical specimen had predictive value. Conclusions. There is a lack of clinical and pathological preoperative variables able to predict Mandard response. Only postoperative pathological parameters related with nCRT response have predictive value.info:eu-repo/semantics/publishedVersio

Diagnóstico de sistemas de dessalinização de água salobra subterrânea em municípios do Estado da Paraíba-Brasil.

Embora, no Semi-Árido brasileiro, predomine o embasamento cristalino, com poços apresentando qualidade comprometida por sais, à tecnologia da dessalinização permite a potabilização dessas águas. Desde 1996 vem sendo implantados, equipamentos de dessalinização por osmose inversa visando o atendimento da demanda hídrica para consumo humano. No entanto, dificuldades estão presentes na implantação dos equipamentos, tais como a falta de operação e manutenção adequadas que causam a paralisação dos mesmos, e como a produção de rejeitos, os quais são água com elevados teores de sais, normalmente despejados ao solo sem qualquer critério, cujo maior impacto tem sido a erosão e a salinidade do solo. Assim, considerando que a Embrapa Semi-Árido pesquisa manejos dos rejeitos, a Fundação Banco do Brasil realizou parceria com a Embrapa, com o objetivo de avaliar 21 sistemas de dessalinização implantados no Estado da Paraíba. O presente artigo tem por objetivo apresentar um diagnóstico da atual situação dos sistemas da Paraíba, principalmente quanto aos aspectos de conservação, manutenção e operacionalização; aos parâmetros técnicos, à qualidade de água e aos impactos ambientais causados pelos rejeitos

Fasting Glucose Metabolism in Pregnancy

The HAPO study found a continuous association between hyperglycemia at 24-32 weeks of gestation, below the diagnostic levels of gestational diabetes mellitus (GDM), and adverse pregnancy outcomes, suggesting the need to reconsider the diagnostic criteria for GDM. Recently, a consensus for diagnosis of diabetes in pregnancy was published, based on the results of the HAPO study. Diagnosing for diabetes is considered already in the first trimester with fasting plasma glucose (FPG), but oral glucose tolerance test is recommended to be performed only at 24-28 weeks of gestation. Identifying all pregnant women at risk for GDM in the first trimester would allow an individualization of obstetric care and establishment of a dietetic and exercise plan since earlier stages of pregnancy with potential benefits for both mother and fetus. The glycemic metabolism varies throughout pregnancy, as insulin resistance increases during pregnancy. However the cut-off values for blood glucose tests in screening and diagnosing GDM are independent of gestational age. The objectives of this study are to verify if the pregnant women with and without GDM diagnosed in the second/third trimester are already different from each other in the first trimester regarding FPG levels and to study the evolution of the FPG throughout pregnancy

Elevação das enzimas hepáticas, persistente e assintomática, como forma de apresentação da doença de Wilson em idade pediátrica

Introdução: A doença de Wilson é uma doença rara, autossómica recessiva, caracterizada por uma alteração no transporte do cobre no fígado, com acumulação progressiva em vários órgãos (fígado, cérebro, rins e córneas). A expressão fenotípica é muito variável desde a elevação das enzimas hepáticas, esteatose ou litíase vesicular, em doentes assintomáticos, até a cirrose ou insuficiência hepática fulminante, ou doença neuropsiquiátrica incapacitante. Objectivo: Caracterizar uma amostra de doentes com doença de Wilson. Métodos: Estudo retrospectivo, incluindo as crianças diagnosticadas entre 2002 e 2011, segundo os critérios da European Association for the Study of the Liver (2012). Variáveis analisadas: antecedentes familiares; idade, dados clínicos, bioquímicos, imagiológicos e histológicos a data do diagnóstico; estudo genético; terapêutica e efeitos colaterais; seguimento e estado actual. Resultados: Foram identificados cinco doentes, três com antecedentes familiares da doença. Todos se apresentavam assintomáticos e com elevação persistente das enzimas hepáticas. Em nenhum havia estigmas de doença hepática crónica. Uma doente tinha excesso de peso. Todos foram tratados com D-penicilamina, interrompida em dois por efeitos colaterais. Actualmente mantem-se assintomáticos, sem evidência de progressão da doença hepática, com um seguimento mediano de 5 anos e 3 meses. Conclusões: A nossa série mostra que a doença de Wilson se pode apresentar com elevação das enzimas hepáticas em crianças assintomáticas. A doente com excesso de peso alerta-nos para a necessidade de rastrear a doença nos que tem excesso de peso/obesidade quando a elevação das enzimas hepáticas e/ou esteatose persistem por mais de seis meses após a perda de peso