Dermatoscopia no Granuloma Facial: Relato de 2 Casos

Granuloma faciale is a rare, benign, idiopathic skin disorder, observed predominantly in caucasian men between the third and fifth decades of life. It is characterized histologically by a mixed inflammatory infiltrate, in which phenomena of vasculitis and fibrosis are associated. It occurs predominantly in the face and has a chronic and slowly progressive course. Its diagnosis is based on clinical and histopathological features, with a recent emphasis on dermoscopy, which reveals aspects that may allow initial differentiation from other diagnoses (sarcoidosis, cutaneous lupus erythematosus, basal cell carcinoma, among others). There are several therapeutic options but with unsatisfactory results. In this article, we report two cases of patients with facial erythematous lesions in which dermoscopy was of great value as a diagnostic tool. Use of this technique will certainly grow in the coming years in relation to this pathology, since, besides providing important disease characteristics it represents a simple and easy way to identify facial granuloma.O granuloma facial é uma patologia cutânea rara, idiopática e benigna, com predomínio em homens caucasianos entre a terceira e quinta décadas de vida. Caracteriza-se histologicamente por um infiltrado inflamatório misto, em que fenômenos de vasculite e fibrose se associam, com predomínio na face, de curso crônico e lentamente progressivo. O diagnóstico baseia-se na história clinica, exame físico e histopatológico, com recente destaque para a dermatoscopia, que revela aspectos que podem possibilitar uma diferenciação inicial com outros diagnósticos (sarcoidose, lúpus eritematoso cutâneo, dentre outros). Existem várias opções terapêuticas propostas, porém com resultados pouco satisfatórios. Neste trabalho, relatamos dois casos de pacientes com lesões eritematosas faciais em que a dermatoscopia teve grande valor como ferramenta diagnóstica. O uso dessa modalidade deve crescer nos próximos anos em relação à essa patologia, já que, além de fornecer características importantes da doença, consiste em uma maneira simples e fácil de identificar o granuloma facial

Síndrome de Graham-Little-Piccardi-Lassueur: relato de caso

Graham-Little-Piccardi-Lassueur syndrome is a rare variant of lichen planus pillar of unknown etiology. It is characterized by progressive scarring alopecia of the scalp, non-scarring alopecia of the axilla and pubis, and follicular lichenoid eruption. We report a classic case of a 74-year-old female patient with hair thinning in the right frontotemporal region, axillary and genital hypotrichosis and keratosis pilaris in the lumbar region and flanks.A Síndrome de Graham-Little-Piccardi-Lassueur é uma variante rara do líquen plano pilar cuja etiologia é desconhecida. É caracterizada pela tríade alopécia cicatricial progressiva de couro cabeludo, alopécia não cicatricial de axilas e púbis e erupção liquenóide folicular. Relatamos caso de paciente feminina de 74 anos com quadro clássico de rarefação pilosa em região frontotemporal direita, hipotricose axilar e genital e queratose pilar em região lombar e flancos

Paracoccidioidomicose com Acometimento Ganglionar e Mucoso - Relato de Caso

Paracoccidioidomycosis (also known as Lutz disease, Lutz-Splendore-Almeida disease, Brazilian blastomycosis or South American blastomycosis) was first described by Lutz nearly a century ago. This is a systemic fungal infection that can appear in two clinical forms: acute / subacute or chronic. Oral lesions of paracoccidioidomycosis are typically characterized by erythematous and finely granular gingival hyperplasia with petechiae. Additionally, shallow ulcers with microgranulations and pinpoint hemorrhages may involve the lips, jugal mucosa, palate, tonsillar pillars and tongue. Lesions have a mulberry-like surface called "moriform stomatitis". Although common, these lesions are under diagnosed and the late recognition of this disease may lead to rapid progression, and death. We report the case of a young patient with generalized lymphadenopathy, moriform stomatitis and constitutional symptoms (fever, weight loss). We emphasize the importance of the dermatologist in the early identification of the cutaneous-mucous lesions typical of paracoccidioidomycosis and in the establishment of an accurate diagnosis.A paracoccidioidomicose (também conhecida como doença de Lutz, doença de Lutz-Splendore-Almeida, blastomicose Brasileira ou blastomicose Sul Americana) foi inicialmente descrita por Lutz há quase um século. Trata-se de uma infecção fúngica sistémica, que pode apresentar-se sob duas formas clínicas: aguda/subaguda ou crónica. As lesões orais da paracoccidioidomicose são tipicamente caracterizadas por hiperplasia gengival eritematosa e finamente granular, com petéquias. Além disso, observam-se úlceras superficiais com micro granulações e ponteados hemorrágicos, que podem envolver lábios, mucosa jugal, palato, pilares amigdalianos e língua. A superfície é semelhante à amora sendo por isso denominada de “estomatite moriforme”. Apesar de comuns, essas lesões são subdiagnosticadas e o reconhecimento tardio desta patologia pode levar à rápida progressão do quadro clínico, por vezes com desfecho fatal. Relatamos o caso de um paciente jovem com adenopatias generalizadas, estomatite moriforme e sintomas constitucionais (febre, perda de peso). Destaca-se a importância do dermatologista na identificação precoce das lesões cutaneomucosas típicas da paracoccidioidomicose e no estabelecimento de um diagnóstico preciso

Lucio's Phenomenon: Response to Alternative Treatment with Multibacilar Polychemotherapy

A hanseníase é uma doença infectocontagiosa de evolução crónica, causada pelo Mycobacterium leprae. Seu curso crónico pode ser interrompido por episódios reacionais agudos ou subagudos. O fenómeno de Lúcio é uma reação imunológica vasculítica que ocorre em doentes com lepra lepromatosa. Surge com máculas purpúricas que evoluem com necrose e ulceração, de forma ascendente, deixando cicatriz atrófica. Os autores descrevem o caso de um paciente de 73 anos, sexo masculino, com lesões ulceronecróticas em membros inferiores e exposição tendinosa em calcâneo. Com base em dados clínico-laboratoriais e exame dermatológico, confirmado diagnóstico de lepra lepromatosa com vasculite do tipo fenómeno de Lúcio. Evoluiu com boa resposta ao esquema alternativo de tratamento com poliquimioterapia multibacilar.Leprosy is an infectious disease of chronic evolution caused by Mycobacterium leprae. Its chronic course can be interrupted by acute or subacute reactional episodes. Lucius phenomenon is a vasculitic immune reaction that occurs in patients with lepromatous leprosy. It appears with purpuric macules that progress to ascending necrosis and ulceration and heal with an atrophic scar. The authors describe the case of a 73-year-old male patient with ulceronecrotic lesions in the lower limbs and tendinous calcaneal exposure. Clinical-laboratory data and dermatological examination confirmed the diagnosis of lepromatous leprosy with vasculitis of the Lucius-like type. It progressed with a good response to the alternative treatment with multibacillary multidrug therapy

Esporotricose na Infância: Mimetizando Leishimaniose: Evolução Favorável com Iodeto de Potássio

Sporotrichosis is a chronic infection of the skin and subcutaneous tissue, caused by the fungus Sporothrix schenkii. In childhood this entity is rare and currently the most frequent in this age group is the zoonotic transmission. The delay in diagnosis and inadvertent use of multiple antimicrobial regimens favor disease progression, therefore causing pain and subsequent scars. The main differential diagnosis for the skin and lymphocutaneous forms is leishmaniasis. Although there are international recommendations for using itraconazole as the first line treatment, it has a level of evidence equal to the saturated solution of potassium iodide and this liquid presentation is more confortable for children.A esporotricose é uma infecção crónica da pele e do tecido celular subcutâneo, causada pelo fungo Sporothrix schenkii. Na infância esta entidade é rara, sendo atualmente a maior ocorrência nessa faixa etária seja pela transmissão zoonótica. O atraso no diagnóstico e o uso inadvertido de múltiplos esquemas antimicrobianos levam à progressão da doença, causando dor e, posteriormente, cicatrizes inestéticas. O diagnóstico diferencial principal em formas cutâneas e linfocutânea é a leishmaniose. Embora haja recomendações internacionais para o uso de itraconazol como primeira linha de tratamento, este tem nível de evidência igual à solução saturada de iodeto de potássio e a apresentação líquida da solução é mais cómoda para crianças

Hiperpigmentação na Doença de Addison: Relato de Caso

The primary adrenal insufficiency or Addison's disease is a rare disorder of the adrenal glands and is a risk factor, since its diagnosis is often not recognized in the early stages of the disease. Currently, its main cause is idiopathic atrophy, but it can occur due to infectious, traumatic and neoplastic causes. Symptoms of the condition include: asthenia, weakness, nausea, weight loss, hypotension, and hyperpigmentation. The skin and mucosa hyperpigmentation is the most characteristic symptom of the disease, but may be present in other differential diagnoses, such as hemochromatosis, chronic kidney disease, hyperthyroidism, ocronosis, among others. We report a case of a patient who was referred for investigation of diffuse cutaneous and mucosa hyperpigmentation. The patient also indicated complaints of weight loss, fatigue, anorexia, hypotension and constipation. Several tests were conducted to research and accomplished the diagnosis of Addison's disease.A insuficiência adrenal primária ou doença de Addison é um raro distúrbio das glândulas supra-renais e representa uma condição de risco, já que seu diagnóstico é frequentemente não reconhecido nas fases inicias da doença. Atualmente sua principal causa é a atrofia idiopática, mas pode decorrer devido a causas infecciosas, traumáticas e neoplásicas. Os sintomas da patologia incluem: astenia, náuseas, perda de peso, hipotensão arterial e hiperpigmentação. A hiperpigmentação cutânea e mucosa é o sinal mais característico da doença, porém pode estar presente em outros diagnósticos diferencias, como: hemocromatose, doença renal crônica, hipertireoidismo, ocronose, entre outras. Relatamos um caso de uma paciente que foi encaminhada para investigação de hiperpigmentação cutânea difusa e mucosa. A paciente ainda referia queixas de perda de peso, fadiga, anorexia, hipotensão e obstipação. Foram realizados diversos exames para investigação e realizado o diagnóstico de doença de Addison

Parinaud’s Oculoglandular Syndrome Caused by Sporothrix schenckii

A síndrome oculoglandular de Parinaud consiste em forma especial de conjuntivite granulomatosa, muitas vezes relacionada à doença da arranhadura do gato, cuja apresentação clássica se caracteriza por uma síndrome febril acompanhada de granuloma conjuntival e linfonodomegalia ipsilateral. As doenças associadas a esta síndrome são doença da arranhadura do gato, infecção por herpes simples, esporotricose, blastomicose e coccidioidomicose, dentre outras. Relatamos o caso de uma paciente com quadro de enantema conjuntival unilateral à direita acompanhado do aparecimento de nódulos em pálpebra ipsilateral. Os exames complementares incluindo cultura confirmaram o diagnóstico de esporotricose. A paciente foi tratada com itraconazol com resolução do quadro.Parinaud's oculoglandular syndrome consists of a special form of granulomatous conjunctivitis, often related to cat scratch disease, whose classic presentation is characterized by a fever, conjunctival granuloma and ipsilateral lymph node enlargement. Diseases associated with this syndrome are cat-scratch disease, herpes simplex infection, sporotrichosis, blastomycosis and coccidioidomycosis, among others. We report the case of a patient with a unilateral conjunctival enanthema on the right eye and nodules on the ipsilateral eyelid. Complementary examinations including culture confirmed the diagnosis of sporotrichosis. The patient was treated with itraconazole and got cured

ESCLERODERMIA JUVENIL

Juvenile scleroderma is a disease that has different features in comparison to scleroderma in adults. Its incidence is rare on infancy. It can be systemic or localized and, this last form is more frequent. We report a case of juvenile scleroderma in a 3-year-old female child presenting with a yellow plaque on the trunk simulating a xantomathous lesion. The lilac ring around the lesion contributed to the construction of the correct diagnostic hypothesis which was confirmed by the histopathology. The precocious diagnosis on this case, allowed the beginning of the treatment on an initial phase of the disease, contributing to a better prognosis for the patient.A esclerodermia juvenil é uma doença que apresenta características diferentes em comparação com a esclerodermia no adulto. Sua incidência é rara na infância. Pode ser sistêmica ou localizada, sendo esta última a mais comum. Relatamos um caso de esclerodermia juvenil em uma criança de 3 anos de idade do sexo feminino apresentando placa amarelada no tronco simulando uma lesão xantomatosa. O halo lilás ao redor da lesão ajudou na formulação correta da hipótese diagnóstica confirmada pela histopatologia. O diagnóstico precoce no caso em questão, possibilitou a instituição do tratamento em uma fase inicial da doença, contribuindo para um melhor prognóstico do paciente

Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): Study protocol for a randomized controlled trial

Background: Acute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART). Methods/Design: ART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH(2)O and peak pressure of 60 cmH2O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure <= 30 cmH2O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay; length of hospital stay; pneumothorax requiring chest tube during first 7 days; barotrauma during first 7 days; mechanical ventilation-free days from days 1 to 28; ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. Discussion: If the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration method.Hospital do Coracao (HCor) as part of the Program 'Hospitais de Excelencia a Servico do SUS (PROADI-SUS)'Brazilian Ministry of Healt

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat