An 85-YO in rural Mississippi: months of tender, erythematous plaques & edema on bilateral hands extending to the elbows & on feet extending below the knees with significant pain
A repeat skin extensive granulomatous inflammation (A), with Ziehl-Neelsen stain clusters of acid-fast bacilli throughout the dermis (B).
Kinyoun stain >9 AFB/high-power field (C & D).
2/19
Prednisone & methotrexate for treatment of reversal reaction, & 10 days later, rifampin, minocycline, & moxifloxacin were added for treatment of leprosy
3 months into therapy: a significant improvement, & he gradually returned to his baseline functional status
4/19 #Doctor
New cases of Leprosy, or Hansen’s disease, caused by Mycobacterium leprae or Mycobacterium lepromatosis in 2020:
✔️127,558 globally, with the highest numbers of cases reported in India, Brazil, and Indonesia
✔️159 in the US
5/19
M. leprae:
✔️a acid-fast, intracellular pathogen that most frequently invades Schwann cells in peripheral nerves & macrophages in the skin
✔️M. leprae DNA was detected from skeletal remains from over 4,000 years ago (the first bacterium found to cause disease in humans)
6/19
Nine-banded armadillos (Dasypus novemcinctus) serve as a zoonotic reservoir for human infection and are considered responsible for some transmission of indigenous cases of leprosy in the United States
7/19
A classification system divides leprosy, based on a spectrum of cell-mediated responses to the disease, into 5 subtypes:
✔️tuberculoid,
✔️borderline tuberculoid,
✔️mid-borderline,
✔️borderline lepromatous, &
✔️lepromatous
8/19
A simpler WHO classification system exists that divides leprosy, based on number of lesions, into
✔️paucibacillary (5 lesions or less) and
✔️multibacillary (more than 5 lesions) leprosy and can be helpful for determining treatment duration
9/19
🔬of tuberculoid infections: well-formed granulomas with epithelioid cells, nerve infiltration, & few bacilli
🔬On lepromatous: disorganized granulomas & foamy macrophages with many bacilli, which appear as circular aggregates of bacilli on AFB stains.
10/19
The borderline forms may have features of both tuberculoid and lepromatous leprosy.
Histopathology in the patient’s case showed poorly defined, granulomatous inflammation with evidence of high bacillary load, suggestive of disease on the lepromatous side of the spectrum.
11/19
Immunologic reactions in leprosy can occur during treatment or spontaneously during the disease course and are associated with increased morbidity.
There are two types of immune reactions.
12/19
The type 1 reaction, or reversal reaction, is a delayed-type hypersensitivity reaction associated with increased erythema of lesions, edema of the hands & feet, neuritis, and nerve impairment, & most often occurs in borderline forms of leprosy.
13/19
The type 2 reaction, or erythema nodosum leprosum, is an immune complex-mediated reaction causing systemic symptoms, including fevers with eruption of multiple, painful subcutaneous nodules, & tends to occur in borderline or lepromatous leprosy.
14/19
Arthritis secondary to immunologic reactions is symmetrical, affecting small joints of the hands and feet, leading to misdiagnosis as various rheumatologic disorders.
15/19
The patient’s overall clinical presentation, including increased pain and edema in his extremities, was felt to be consistent with immunologic reaction-associated arthritis and neuritis.
16/19
Management was aimed at controlling the inflammatory component of the disease using immunomodulation first followed by antimycobacterial therapy. (Fig, noted 3 months into treatment).
17/19
A diagnosis of leprosy should be suspected in a patient presenting with rash and biopsy findings positive for AFB with no growth on culture.
Molecular testing using a multilocus approach to mycobacteria can be used to confirm diagnosis.
18/19
Symptoms of worsening pain, edema, paralysis, and neuropathy in the extremities should additionally prompt concern for possible immunologic reaction to guide initiation of immunosuppressive regimen.
19/19
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A 32-YO HIV+ patient, from a rural area of Colombia, severely immunosuppressed (<50 CD4 cells/mm3): ulcers in lower limbs, was found with a larvae coming out from one ulcer (Figure). 1/5
W Villamil et al. Rev Panam Enf Inf 2018; 1(1):40-41.
#parasitology #microbiology
The larva was identified, as possible Tenebrio molitor.
CANTHARIASIS: ULCE INFESTACIÓN DUE TENEBRIO MOLITORIN IN AN AIDS PATIENT
Patient was treated with trimethoprim with a successful evolution 2/5
#healthcare #primarycare
Canthariasis is a rare #ectoparasitic condition.
It is the second important insectal disease after myiasis.
Several species of beetles are reported to cause the disease in gastrointestinal tract, urogenital system, nasal sinuses, ears & faces of mammals. 3/5
23 años ♀️, LES en tratamiento inmunosupresor: pápulas asintomáticas de un año de evolución en el párpado izquierdo, con aumento progresivo en número y tamaño. 1/5
El molusco contagioso:
✔️infección viral cutánea,
✔️usualmente benigna y autolimitada
El virus del molusco contagioso se trasmite habitualmente por contacto directo entre individuos infectados, durante las relaciones sexuales o mediante objetos contaminados 3/5
6 años♂️: dolor y alopecia en placas en cuero cabelludo de 3 meses de evolución; en las últimas 48 horas, fiebre y cefalea, adenopatías cervicales < 2 cm. 1/4
@lauracatty95@juliaserralabos@SeanPYeh@ContinuumAEP@aepediatria ✔️Una o varias placas dolorosas con folículos y pústulas rodeadas de áreas de alopecia eritematosas; pueden evolucionar a abscesos.
✔️“signo de la espumadera”: salida de pus por los orificios de los folículos pilosos al hacer presión lateral sobre la zona. 3/4
A 44-yo♂️, HIV +, CD4 cell count of 86/mL, viral load of 35,900 copies/mL: a 1-month history of fevers and pruritic blackish-brown lamellated plaques on the limbs and scalp.
¼
👇
DOI: 10.1056/NEJMicm2213894 #IDtwitter#dermatology
A RPR titer of 1:32.
A Treponema pallidum particle agglutination: ➕.
A skin-biopsy of the left forearm 🔬: diffuse dermal lymphocytes and histiocytes admixed with a plasma-cell infiltrate.
Routine staining methods (haematoxylin & eosin & Warthin-Starry) can identify spirochetes on the surface of enterocytes.
Histologically, characteristic findings include a decrease in microvilli &a predominantly eosinophilic inflammatory infiltrate.
3/10
Lactante, un mes de vida: fiebre, placa en la cara ligeramente sobreelevada, eritematosa, con coloración anaranjada periférica, delimitada, y con aumento de temperatura a la palpación 1/7
@ContinuumAEP@aepediatria ERISIPELA
✔️infección superficial que afecta a la dermis superior, el tejido celular subcutáneo y a veces al sistema linfático,
✔️causada en la mayoría de los casos por S. pyogenes o estreptococos de los grupos B, C o G. 2/7
@ContinuumAEP@aepediatria Origen: interrupción de la barrera cutánea por picaduras de insecto, erosiones, etc.
Comienzo: agudo
Placa eritematosa con bordes bien definidos y ligeramente elevados
Localización predilecta: miembros inferiores y cara
Frecuente: adenopatías regionales. 3/7