What is your diagnosis?
Case for diagnosis. Erythematous and infiltrated plaques in the infrahyoid region
Natália Tenório Cavalcante Bezerra
, Antonio Pedro Mendes Schettini, André Luiz Leturiondo, Liana Hortencia Miranda Tubilla Mathias
Corresponding author
Fundação Alfredo da Matta, Manaus, AM, Brazil
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A pruritic eruption of keratotic papules over the face and neck" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "100" "paginaFinal" => "102" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 805 "Ancho" => 1750 "Tamanyo" => 223547 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Multiple skin-colored to erythematous to brownish, 1 − 2 mm papules, with a slightly keratotic center, sometimes coalescing into verrucous plaques; koebnerization is also present.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Maria Relvas, Joana Calvão, Inês Coutinho, José Carlos Cardoso" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Maria" "apellidos" => "Relvas" ] 1 => array:2 [ "nombre" => "Joana" "apellidos" => "Calvão" ] 2 => array:2 [ "nombre" => "Inês" "apellidos" => "Coutinho" ] 3 => array:2 [ "nombre" => "José Carlos" "apellidos" => "Cardoso" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S2666275220303507" "doi" => "10.1016/j.abdp.2020.06.005" "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/S2666275220303507?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059620302993?idApp=UINPBA00008Z" "url" => "/03650596/0000009600000001/v3_202102051036/S0365059620302993/v3_202102051036/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S0365059620303007" "issn" => "03650596" "doi" => "10.1016/j.abd.2020.07.003" "estado" => "S300" "fechaPublicacion" => "2021-01-01" "aid" => "286" "copyright" => "Sociedade Brasileira de Dermatologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by/4.0/" "subdocumento" => "crp" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Images in Dermatology</span>" "titulo" => "Topical corticosteroid induced ulcerated striae" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "94" "paginaFinal" => "96" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 703 "Ancho" => 1305 "Tamanyo" => 171623 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A), Two superficial oval ulcers over striae in the inguinal region. 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Erythematous and infiltrated plaques in the infrahyoid region" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "97" "paginaFinal" => "99" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Natália Tenório Cavalcante Bezerra, Antonio Pedro Mendes Schettini, André Luiz Leturiondo, Liana Hortencia Miranda Tubilla Mathias" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Natália Tenório Cavalcante" "apellidos" => "Bezerra" "email" => array:1 [ 0 => "ntltenorio@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Antonio Pedro Mendes" "apellidos" => "Schettini" ] 2 => array:2 [ "nombre" => "André Luiz" "apellidos" => "Leturiondo" ] 3 => array:2 [ "nombre" => "Liana Hortencia Miranda Tubilla" "apellidos" => "Mathias" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Fundação Alfredo da Matta, Manaus, AM, Brazil" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 676 "Ancho" => 900 "Tamanyo" => 130520 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Presence of several acid-fast bacilli in the dermis (Wade, ×100).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 46-year-old male presented two erythematous infiltrated plaques for 30 days, with changes in thermal, tactile and painful sensitivity on the infrahyoid region (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). He also reported diarrhea and the loss of 8 kg in four months. The bacilloscopy was negative. Histopathology showed a diffuse inflammatory dermal infiltrate made up of epithelioid histiocytes and focal foam cells, lymphocytes, and giant Langhans cells, distributed around vessels, adnexa, and nerves (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Several isolated and fragmented bacilli were demonstrated in the papillary dermis using the Wade-Fite method (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The polymerase chain reaction (PCR) was positive for Mycobacterium leprae, and culture for other mycobacteria was negative. Serology for syphilis and HIV was positive, with a CD4 of 223 and a viral load of 221,601 copies. With the diagnosis of borderline-virchowian leprosy, he started treatment with multibacillary multidrug therapy, benzathine penicillin, and antiretroviral therapy, with partial regression of the lesions after two months (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">What is your diagnosis?</span><p id="par0010" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a)</span><p id="par0015" class="elsevierStylePara elsevierViewall">Atypical mycobacteriosis</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b)</span><p id="par0020" class="elsevierStylePara elsevierViewall">Sarcoidosis</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c)</span><p id="par0025" class="elsevierStylePara elsevierViewall">Leprosy</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">d)</span><p id="par0030" class="elsevierStylePara elsevierViewall">Cutaneous tuberculosis</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Due to the interactions between Mycobacterium leprae (<span class="elsevierStyleItalic">M. leprae</span>) and the host's immune response, leprosy presents great clinical polymorphism, justifying the several classifications of the disease proposed throughout history.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">There was an assumption that, in patients co-infected with leprosy and HIV, the compromised immune system could interfere in several clinical-pathological aspects of leprosy.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However, studies have shown that there is no direct impact on the rate of detection of the disease in HIV-positive patients, and that the classic clinical forms prevail. Leprosy reactions also do not appear to be more frequent, and the treatment is effective at the usual doses and duration.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In the reported case, the patient had an unusual clinical picture, mimicking various diseases, making it difficult to diagnose and prescribe the appropriate therapeutic regimen. The conclusion was established by tests not available in primary healthcare units. Bacilloscopy, performed by intradermal scraping of four sites, one of them being the infrahyoid lesion, was negative even after being repeated. In an unusual way, the histopathological examination showed that the bacilli were located at the limit between the papillary and reticular dermis and were restricted to a certain field, rather than distributed diffusely. The clinical-pathological categorization of the patient then became a challenge.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The authors chose to classify it as borderline-virchowian (Ridley and Jopling classification) based on the histopathological findings that showed characteristics of the tuberculoid pole (epithelial granulomas) and the virchowian pole (vacuolated histiocytes) in the same biopsy, possibly registering a transition from the borderline-borderline form to borderline-virchowian.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Routine examinations at the reference service enabled the diagnosis of comorbidities (AIDS and syphilis) in this patient. It was also possible to perform tests such as histopathology and PCR, which allowed the diagnostic conclusion of leprosy in an atypical clinical lesion.</p><p id="par0060" class="elsevierStylePara elsevierViewall">It is important to emphasize that the basic health care network must have reference services which provide technical capabilities to confirm or rule out the diagnosis of leprosy in patients whose clinical presentation differs from the usual.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0065" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors’ contributions</span><p id="par0070" class="elsevierStylePara elsevierViewall">Natália Tenório Cavalcante Bezerra: Drafting and editing of the manuscript; critical review of the literature.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Antonio Pedro Mendes Schettini: Approval of the final version of the manuscript; drafting and editing of the manuscript; critical review of the manuscript.</p><p id="par0080" class="elsevierStylePara elsevierViewall">André Luiz Leturiondo: Intellectual participation in propaedeutic and/or therapeutic conduct of studied cases.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Liana Hortência Miranda Tubilla Mathias: Intellectual participation in propaedeutic and/or therapeutic conduct of studied cases.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1461422" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1331606" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "What is your diagnosis?" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 5 => array:2 [ "identificador" => "sec0020" "titulo" => "Financial support" ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Authors’ contributions" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-10-13" "fechaAceptado" => "2020-03-05" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1331606" "palabras" => array:3 [ 0 => "Diagnosis, differential" 1 => "HIV infections" 2 => "Leprosy" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Leprosy is a chronic infectious disease caused by <span class="elsevierStyleItalic">Mycobacterium leprae</span> and, depending on the host immune status, presents different clinical forms. This report describes the case of a 46-year-old man who had hypoesthetic lesions in the infrahyoid region for 30 days. The bacilloscopy was negative. The anatomopathological examination showed alterations corresponding to the tuberculoid pole (epithelioid histiocytes) and virchowian pole (foamy histiocytes), compatible with borderline-virchowian leprosy (Ridley and Jopling classification). Rapid tests for HIV I, II, and syphilis were positive, with a CD4 count of 223. The patient started treatment with multibacillary multidrug therapy, antiretroviral therapy, and benzathine penicillin, with marked clinical improvement in two months.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Bezerra NTC, Schettini APM, Leturiondo AL, Mathias LHMT. Case for diagnosis. Erythematous and infiltrated plaques in the infrahyoid region. An Bras Dermatol. 2021;96:97–9.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Fundação Alfredo da Matta, Manaus, AM, Brazil.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1104 "Ancho" => 750 "Tamanyo" => 139995 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythematous and infiltrated plaques, confluent in the infrahyoid region, with well-defined edges.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 601 "Ancho" => 1250 "Tamanyo" => 288507 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A), Dermal granulomatous inflammatory process with epithelioid cells, giant cells and lymphocytes (Hematoxylin & eosin, ×100). (B), Dermal inflammatory process with foamy histiocytes (Hematoxylin & eosin, ×400).</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 676 "Ancho" => 900 "Tamanyo" => 130520 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Presence of several acid-fast bacilli in the dermis (Wade, ×100).</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 599 "Ancho" => 900 "Tamanyo" => 71258 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Aspect of the lesions after two months of multidrug treatment for multibacillary leprosy. The lesions are impregnated with clofazimine.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "WHO Expert Committee on Leprosy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "World Health Organization" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "World Health Organ Tech Rep Ser." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 23 | 8 | 31 |
| 2024 October | 108 | 74 | 182 |
| 2024 September | 136 | 88 | 224 |
| 2024 August | 164 | 124 | 288 |
| 2024 July | 138 | 109 | 247 |
| 2024 June | 126 | 86 | 212 |
| 2024 May | 97 | 67 | 164 |
| 2024 April | 104 | 89 | 193 |
| 2024 March | 92 | 66 | 158 |
| 2024 February | 117 | 88 | 205 |
| 2024 January | 102 | 48 | 150 |
| 2023 December | 56 | 60 | 116 |
| 2023 November | 76 | 69 | 145 |
| 2023 October | 68 | 75 | 143 |
| 2023 September | 67 | 75 | 142 |
| 2023 August | 57 | 33 | 90 |
| 2023 July | 70 | 56 | 126 |
| 2023 June | 58 | 47 | 105 |
| 2023 May | 61 | 20 | 81 |
| 2023 April | 38 | 22 | 60 |
| 2023 March | 52 | 35 | 87 |
| 2023 February | 48 | 38 | 86 |
| 2023 January | 32 | 22 | 54 |
| 2022 December | 45 | 27 | 72 |
| 2022 November | 66 | 58 | 124 |
| 2022 October | 78 | 53 | 131 |
| 2022 September | 49 | 69 | 118 |
| 2022 August | 38 | 42 | 80 |
| 2022 July | 36 | 60 | 96 |
| 2022 June | 43 | 57 | 100 |
| 2022 May | 26 | 48 | 74 |
| 2022 April | 40 | 49 | 89 |
| 2022 March | 45 | 82 | 127 |
| 2022 February | 30 | 35 | 65 |
| 2022 January | 63 | 94 | 157 |
| 2021 December | 40 | 61 | 101 |
| 2021 November | 50 | 69 | 119 |
| 2021 October | 59 | 83 | 142 |
| 2021 September | 45 | 61 | 106 |
| 2021 August | 50 | 56 | 106 |
| 2021 July | 50 | 48 | 98 |
| 2021 June | 52 | 53 | 105 |
| 2021 May | 90 | 97 | 187 |
| 2021 April | 219 | 366 | 585 |
| 2021 March | 165 | 107 | 272 |
| 2021 February | 67 | 17 | 84 |
| 2021 January | 43 | 20 | 63 |
| 2020 December | 10 | 11 | 21 |
| 2020 November | 1 | 2 | 3 |
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