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Beware of reflectance confocal microscopy artifacts when searching hyphae in acral skin – Reply
John Verrinder Veasey
Infectious Dermatoses Sector, Clínica de Dermatologia, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
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array:23 [ "pii" => "S0365059619301801" "issn" => "03650596" "doi" => "10.1016/j.abd.2019.04.014" "estado" => "S300" "fechaPublicacion" => "2020-01-01" "aid" => "125" "copyright" => "Sociedade Brasileira de Dermatologia" "copyrightAnyo" => "2019" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by/4.0/" "subdocumento" => "cor" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 6 "PDF" => 6 ] "Traduccion" => array:1 [ "pt" => array:19 [ "pii" => "S2666275220300217" "issn" => "26662752" "doi" => "10.1016/j.abdp.2019.04.011" "estado" => "S300" "fechaPublicacion" => "2020-01-01" "aid" => "125" "copyright" => "Sociedade Brasileira de Dermatologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by/4.0/" "subdocumento" => "cor" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "pt" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Correspondência</span>" "titulo" => "Cuidado com artefatos à microscopia confocal de reflectância ao pesquisar hifas na pele acral – Resposta" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "130" "paginaFinal" => "132" ] ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1553 "Ancho" => 2917 "Tamanyo" => 474515 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Dois casos de tinha negra apresentam aspecto clínico clássico (A1, B1). Dermatoscopia de ambos os casos, com estruturas lineares hipercrômicas curtas na epiderme (A2, B2). Exame micológico direto (KOH 20%), com hifas septadas demáceas curtas (A3 200<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>, B3 400<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "John Verrinder Veasey" "autores" => array:1 [ 0 => array:2 [ "nombre" => "John Verrinder" "apellidos" => "Veasey" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0365059619301801" "doi" => "10.1016/j.abd.2019.04.014" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059619301801?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275220300217?idApp=UINPBA00008Z" "url" => "/26662752/0000009500000001/v1_202003280637/S2666275220300217/v1_202003280637/pt/main.assets" ] ] "itemAnterior" => array:19 [ "pii" => "S0365059619301795" "issn" => "03650596" "doi" => "10.1016/j.abd.2019.04.013" "estado" => "S300" "fechaPublicacion" => "2020-01-01" "aid" => "124" "copyright" => "Sociedade Brasileira de Dermatologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by/4.0/" "subdocumento" => "cor" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 8 "formatos" => array:2 [ "EPUB" => 1 "PDF" => 7 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Correspondence</span>" "titulo" => "Beware of reflectance confocal microscopy artifacts when searching hyphae in acral skin" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "129" "paginaFinal" => "130" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 881 "Ancho" => 900 "Tamanyo" => 200252 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Reflectance confocal microscopy image of normal acral skin of a healthy person shows artifacts presenting as stellate hyper-reflective bodies in the epidermis (yellow arrows; asterisks indicate acrosyringia).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Elisa Cinotti, Jean Luc Perrot, Pietro Rubegni" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Elisa" "apellidos" => "Cinotti" ] 1 => array:2 [ "nombre" => "Jean Luc" "apellidos" => "Perrot" ] 2 => array:2 [ "nombre" => "Pietro" "apellidos" => "Rubegni" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S2666275220300205" "doi" => "10.1016/j.abdp.2019.04.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275220300205?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059619301795?idApp=UINPBA00008Z" "url" => "/03650596/0000009500000001/v3_202003240622/S0365059619301795/v3_202003240622/en/main.assets" ] "en" => array:17 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Correspondence</span>" "titulo" => "Beware of reflectance confocal microscopy artifacts when searching hyphae in acral skin – Reply" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "130" "paginaFinal" => "132" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "John Verrinder Veasey" "autores" => array:1 [ 0 => array:3 [ "nombre" => "John Verrinder" "apellidos" => "Veasey" "email" => array:1 [ 0 => "johnveasey@uol.com.br" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Infectious Dermatoses Sector, Clínica de Dermatologia, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil" "identificador" => "aff0005" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1484 "Ancho" => 2917 "Tamanyo" => 406572 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A1, B1, C1: clinical aspect of superficial mycoses. A2, B2, C2: direct mycological examinations (KOH 20%) corresponding to clinical presentations, presenting in all cases thin and long hyaline septated hyphae (x100, x400, x200, respectively).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">I would like to thank Cinotti et al. for their interest in our paper about tinea nigra's findings at confocal microscopy, as well as the opportunity offered by the editors of this journal to answer the points raised by the authors in the article “Beware of reflectance confocal microscopy artifacts when searching hyphae in acral skin”.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The etiological agent of tinea nigra, <span class="elsevierStyleItalic">Hortaea wernekii</span>, is a dematiaceous geophilic fungus. The dermoscopic features of this disease consist of a fibrillar hyperchromic pattern, and the direct mycological examination (DME) presents short and thick dematiaceous hyphae, corresponding to the described dermoscopic findings.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,2</span></a> Other cases seen in our service with fungal culture isolating <span class="elsevierStyleItalic">H. wernekii</span> are compatible with these findings (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Such facts had led us to believe that the images identified by reflectance confocal microscopy (RCM) in our article would be compatible with the hyphae of <span class="elsevierStyleItalic">H. wernekii</span> parasitizing the epidermis. It is noteworthy that the morphology of short thick structures presented at dermoscopic examination and DME were compatible with those evidenced by the RCM.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">As for the images presented in the response correspondence, composed of few thin and elongated septate hyphae at the surface of the epidermis, I would like to point out that in human microbiome studies there are evidence of filamentous fungi in the skin of healthy patients.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4,5</span></a> Such agents, when provoking superficial mycoses, present at the DME fine and long hyphae (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), a morphology that has also been described in RCM analyzes.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6–9</span></a> An important fact in Cinotti et al. article was the lack of fungal culture of the specimen evidenced by RCM images, making it impossible to confirm that the hyphae visualized were of <span class="elsevierStyleItalic">H. wernekii</span>. I believe that these facts should be taken into account when finding thin and long hyphae in the analysis of tinea nigra images, since the other tests performed for its diagnosis usually do not present these thin structures. Unfortunately, it is not possible to evaluate by the RCM if the hyphae presented in the cases are hyaline or dematiaceous, since both melanin and the cellular wall of the fungi present white color by the RCM examination.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Finally, it cannot be denied that the use of RCM for the analysis of tinea nigra presents various pitfalls, either due to the presence of filamentous fungal structures that could erroneously be considered compatible with <span class="elsevierStyleItalic">H. wernekii</span>, or to the presence of epidermal artifacts that could be considered as fungal structures. Further studies are required to help us elucidate the structures of this dermatosis.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0030" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Author's contribution</span><p id="par0035" class="elsevierStylePara elsevierViewall">John Verrinder Veasey: Approval of the final version of the manuscript; elaboration and writing of the manuscript; collection, analysis, and interpretation of data; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cased; critical review of the literature; critical review of the manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Author's contribution" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-03-10" "fechaAceptado" => "2019-04-29" "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Veasey JV. Beware of reflectance confocal microscopy artifacts when searching hyphae in acral skin – Reply. An Bras Dermatol. 2020;95:130–2.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Dermatology Clinic, Hospital da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1553 "Ancho" => 2917 "Tamanyo" => 474515 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Two cases of tinea nigra with classic clinical presentation (A1, B1). Dermoscopy of both cases, with short hyperchromic linear structures in the epidermis (A2, B2). Direct mycological examination (KOH 20%), with short dematiaceous septate hyphae (A3 x200, B3 x400).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1484 "Ancho" => 2917 "Tamanyo" => 406572 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A1, B1, C1: clinical aspect of superficial mycoses. A2, B2, C2: direct mycological examinations (KOH 20%) corresponding to clinical presentations, presenting in all cases thin and long hyaline septated hyphae (x100, x400, x200, respectively).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dermoscopy revealing a case of Tinea Nigra" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. Delgado" 1 => "P.R. Criado" 2 => "G. 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Meneses" 2 => "F.O. da Silva" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Int J Dermatol" "fecha" => "2018" "volumen" => "58" "paginaInicial" => "849" "paginaFinal" => "851" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0090" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reflectance confocal microscopy for cutaneous infections and infestations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "E. Cinotti" 1 => "J.L. Perrot" 2 => "B. Labeille" 3 => "F. Cambazard" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/jdv.13254" "Revista" => array:6 [ "tituloSerie" => "J Eur Acad Dermatol Venereol" "fecha" => "2016" "volumen" => "30" "paginaInicial" => "754" "paginaFinal" => "763" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26387660" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/03650596/0000009500000001/v3_202003240622/S0365059619301801/v3_202003240622/en/main.assets" "Apartado" => array:4 [ "identificador" => "81766" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Correspondence" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/03650596/0000009500000001/v3_202003240622/S0365059619301801/v3_202003240622/en/main.pdf?idApp=UINPBA00008Z&text.app=https://clinics.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059619301801?idApp=UINPBA00008Z" ]
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| 2022 December | 53 | 22 | 75 |
| 2022 November | 69 | 44 | 113 |
| 2022 October | 60 | 50 | 110 |
| 2022 September | 48 | 64 | 112 |
| 2022 August | 36 | 50 | 86 |
| 2022 July | 38 | 51 | 89 |
| 2022 June | 41 | 44 | 85 |
| 2022 May | 32 | 48 | 80 |
| 2022 April | 39 | 42 | 81 |
| 2022 March | 41 | 58 | 99 |
| 2022 February | 23 | 52 | 75 |
| 2022 January | 34 | 77 | 111 |
| 2021 December | 34 | 46 | 80 |
| 2021 November | 33 | 43 | 76 |
| 2021 October | 41 | 64 | 105 |
| 2021 September | 33 | 39 | 72 |
| 2021 August | 45 | 44 | 89 |
| 2021 July | 30 | 18 | 48 |
| 2021 June | 34 | 32 | 66 |
| 2021 May | 54 | 56 | 110 |
| 2021 April | 149 | 247 | 396 |
| 2021 March | 50 | 41 | 91 |
| 2021 February | 20 | 18 | 38 |
| 2021 January | 16 | 15 | 31 |
| 2020 December | 25 | 22 | 47 |
| 2020 November | 13 | 10 | 23 |
| 2020 October | 14 | 7 | 21 |
| 2020 September | 10 | 6 | 16 |
| 2020 August | 12 | 10 | 22 |
| 2020 July | 5 | 6 | 11 |
| 2020 June | 10 | 8 | 18 |
| 2020 May | 13 | 15 | 28 |
| 2020 April | 4 | 2 | 6 |
| 2020 March | 7 | 1 | 8 |
| 2020 January | 0 | 6 | 6 |
Show all
