Unknown: Bluish-gray macules on the hands of a healthy 34 year-old man

A 34 year-old man presented with asymptomatic bluish-gray macules on his hands that had developed over the previous 2 years. He was otherwise healthy and was on no regular medication. A detailed clinical history and histologic examination allowed the diagnosis.Histopathologic examination showed deposits of aggregated granules of black pigment in the dermis, localized preferentially around the sweat glands. This was consistent with the deposition of silver salts. Given the absence of systemic complaints or other signs and symptoms, a conservative approach was adopted. The lesions remain unchanged after one year of follow up.The wide range of uses for silver allows exposure to its compounds (metal, soluble and insoluble compounds) through different routes of entry, namely direct contact, ingestion, inhalation, and puncture. [1] This exposure is usually occupational, iatrogenic, or accidental. [1] Argyria is an exceedingly rare disease that became uncommon because medications containing silver are no longer used and occupational protection has evolved significantly. [2] It is caused by the deposition of silver grains in the skin and is further divided into localized and generalized forms, according to the route of entry. [1-4] Localized argyria is caused by direct contact with silver (the tiny particles penetrate the skin through the sweat glands) or puncture. [1, 3, 4] These deposits remain indefinitely in the skin and are characterized by a bluish gray color, more prominent in the photo-exposed areas. [3, 4] In the localized forms, patients usually don’t have systemic symptoms and the problem is cosmetic. [1-4] Given the improvement in the safety of working conditions, occupational argyria cases are becoming quite uncommon. [1-4

A local landscape in transition between production and consumption: can new management arrangements preserve the local landscape character?

Around towns in the Alentejo region, the landscape is dominated by a characteristic agricultural small scale mosaic. These areas are central in the region landscape character, – even if the large scale latifundia landscape of the extensive silvo-pastoral systems is most commonly associated with the region. In the last two decades, these parcels became extremely attractive for new comers, who settle in the rural context as residents, week-end visitors, being often also lifestyle farmers. The paper presents a case-study landscape, in Montemor-o-Novo, a small town 100 km from Lisbon, highly subject to the pressure for consumption uses, by urban users. The study shows that the new owners, even if they have settled in the area due to the tranquility and social bindings of the rural, end up doing farming, with new or reshaped production objectives, markets and models, but at the same time maintaining the traditional farm systems. Thus, the landscape character is maintained, so far. Nevertheless, the role of these neo-rurals and lifestyle farmers is still an unseen role, both by the agriculture and the planning sectors. And thus the question is, whether the combination of actors and land management drivers will continue maintaining the landscape in the futur

Vesico-bullous subacute cutaneous lupus erythematosus – An uncommon entity successfully treated with dapsone and hydroxychloroquine

Vesico-bullous subacute cutaneous lupus erythematosus is an uncommon and severe presentation. The authors report an exuberant case of vesico-bullous subacute cutaneous lupus erythematosus successfully treated with dapsone and hydroxychloroquin

Ashy Dermatosis - Treatment with Clofazimine

A Ashy dermatosis, ou erythema dyscromicum perstans, é uma dermatose rara de etiologia desconhecida. Os autores descrevem o caso de um homem de 46 anos saudável, com história de lesões cutâneas cinzentas assintomáticas no tronco com 1 ano de evolução. A constelação dos achados clínicos, histológicos e laboratoriais permitiu efectuar o diagnóstico de Ashy dermatosis. O doente iniciou tratamento com clofazimina oral, verificando-se resolução completa do quadro clínico e mantendo-se sem lesões cutâneas ao fim de 6 meses de vigilância. Estão descritas inúmeras opções terapêuticas para a Ashy dermatosis, no entanto nenhuma eficaz de forma consistente. O tratamento com clofazimina tem sido defendido devido ao seu efeito cosmético e a uma possível acção anti-inflamatória e imunomoduladora. Este caso documenta a eficácia terapêutica da clofazimina num doente com Ashy dermatosi

The effects of grazing management in montado fragmentation and heterogeneity

The Portuguese silvo-pastoral system montado is broadly classified as a High Nature Value (HNV) system since it corresponds to farmland hosting high biodiversity levels, and such biodiversity depends on specific land use practices. However, in recent decades a decline both in the totalmontado area and in the tree cover density within the montado has been observed, driven mainly by management changes. This decline may result in biodiversity loss. Grazing is a central aspect determining the long-term sustainability of the montado system and it has implications also on themontado structural diversity, particularly on connectivity and heterogeneity, which is crucial for the maintenance of montado HNV. The aim of this paper is to demonstrate how variations in montadostructural diversity are correlated with grazing management and its implications on the value of the system for conservation. The empirical data derives from a case study composed of 41 montadofarms in two municipalities of the Alentejo region. Data on grazing management, biophysical and spatial factors were collected and several metrics were calculated to assess montado fragmentation and heterogeneity. A multivariate analysis was performed using generalized additive models. Results show that different grazing patterns, depending on stocking density and grazing animal type, are correlated with variations in montado fragmentation and heterogeneity. Particularly, cattle’s grazing is shown to have adverse effects on the montado fragmentation, while sheep grazing is shown to have stronger impacts on the heterogeneity within the montado patches

Dermatofibroma múltiplo agrupado congênito e dermatofibromas múltiplos eruptivos - apresentações singulares de uma entidade comum

Dermatofibroma is one of the most common entities seen in dermatology clinical practice. Several clinical subtypes have nevertheless been described, all of them of uncommon occurrence. The authors present two rare clinical variants of dermatofibromas: congenital multiple clustered dermatofibroma (the presented case is the 4th congenital case to be reported so far) and multiple eruptive dermatofibromas developing in the setting of a Sjögren's syndrome. Since the uncommon subtypes may not be clinically evident, dermatologists should familiarize themselves with their main features and we advise a high level of clinical suspicion in order to reach the correct diagnosis

Cutaneous manifestations of antiphospholipid syndrome: a review of the clinical features, diagnosis and management

Antiphospholipid syndrome is a relatively recent systemic autoimmune disorder defined by thrombotic events and/or obstetric complications in the presence of persistent elevated antiphospholipid antibodies. It is characterized by a wide spectrum of clinical presentations and virtually any organ system or tissue may be affected by the consequences of vascular occlusion. Diagnosis is sometimes difficult and although classification criteria have been published and revised there remain ongoing issues regarding nomenclature, expanding clinical features, laboratory tests and management and much still has to be done. Cutaneous manifestations are common and frequently the first sign of the disease. Although extremely diverse it’s important to know which dermatological findings should prompt consideration of antiphospholipid syndrome and the appropriate management for those patients. Much has been debated about when to consider antiphospholipid syndrome and consensus still does not exist, however in spite of being a diagnostic challenge clinicians should know when to look for antiphospholipid antibodies since an early diagnosis is important to prevent further and serious complications. In this article we focus on the cutaneous features that should raise suspicion on the presence of antiphospholipid syndrome and on the complex management of such patients. Many other dermatological signs related to this syndrome have been described in the literature but only occasionally and without consistency or statistic impact and therefore will not be considered hereO síndrome antifosfolipidico é uma patologia auto-imune relativamente recente definida por eventos trombóticos e/ou complicações obstétricas na presença de anticorpos antifosfolípido elevados persistentes. Caracteriza-se por um vasto leque de apresentações clínicas e virtualmente qualquer sistema orgânico ou tecido pode ser afectado por oclusão vascular. O diagnóstico é por vezes difícil e, apesar de critérios de classificação terem sido publicados e revistos, muitas dúvidas persistem relativamente à nomenclatura, características clínicas, testes laboratoriais e abordagem destes doentes. As manifestações cutâneas são comuns e, frequentemente, o primeiro sinal da doença. Apesar da grande variabilidade, é importante reconhecer os achados dermatológicos que devem levantar a suspeita de um síndrome antifosfolipidico, assim como a abordagem adequada destes doentes. Muito tem sido debatido sobre quando considerar o diagnóstico desta entidade, não havendo ainda consenso neste assunto; no entanto, apesar de ser um desafio diagnóstico, é importante saber quando investigar a presença de anticorpos antifosfolípidos, uma vez que um diagnóstico precoce é crucial para prevenir complicações futuras graves. No presente artigo os autores descrevem as manifestações dermatológicas que devem fazer considerar o diagnóstico com enfoque na abordagem complexa destes doentes. Têm sido descritas na literatura muitas outras alterações cutâneas relacionadas com esta entidade, no entanto, apenas de forma ocasional e sem consistência ou impacto estatístico, pelo que não serão consideradas

A dramatic case of Behçet disease successfully treated with infliximab

Behçet disease is a chronic relapsing systemic disease with possible life-threatening presentations. Management of this disease can be challenging and reports of the off-label use of anti-TNFα agents for the treatment of severe manifestations are increasing, with good results. The authors report a case of Behçet disease with a sudden and severe multi-systemic onset successfully treated with infliximab

Exuberant cutaneous ulcers on the buttocks caused by multi-resistant

Cutaneous infection develops because of environmental and local factors, host immunity, and organism adherence and virulence. The authors report a case of exuberant cutaneous ulcers on the buttocks of a diabetic patient. Microbiologic examination allowed the identification of Klebsiella pneumoniae and complete resolution was achieved with the appropriate antibioti

Langerhans cell histiocytosis: Two clinical presentations in the same patient

Langerhans cell histiocytosis (LCH) is a heterogeneous group of diseases characterized by a pathological proliferation of cells phenotypically similar to Langerhans cells. The disease course is variable, alternating between resolving and potentially fatal forms. The diagnosis is based on clinical appearance and confirmed by CD1a positivity and / or immunohistochemistry. We report the case of a male child of 3 months with two different presentations of Langerhans cell-histiocytosis (LCH) at different times. The first presentation was classified as a self-healing LCH (formerly known as Hashimoto-Pritzker). The last presentation, although clinically suggestive of Letterer-Siwe (former designation), was not associated with systemic disease. This emphasizes that LCH cannot be compartmentalized into four groups, but considered a single disease with a wide spectrum of clinical presentations. This case underscores the importance of frequent and long-term follow-up of these patients