What is your diagnosis?
Case for diagnosis. Ulcer and papular lesions in a patient with diabetes mellitus. Protothecosis
Larissa Daniele Machado Góes
, Vinícius da Silva Monteiro, Ana Tereza Orsi de Souza
Corresponding author
Fundação de Dermatologia Tropical e Venereologia Alfredo da Matta, Manaus, AM, Brazil
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Ulcer and papular lesions in a patient with diabetes mellitus. Protothecosis" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "613" "paginaFinal" => "616" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Larissa Daniele Machado Góes, Vinícius da Silva Monteiro, Ana Tereza Orsi de Souza" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Larissa Daniele Machado" "apellidos" => "Góes" "email" => array:1 [ 0 => "larissadaniele55@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Vinícius da Silva" "apellidos" => "Monteiro" ] 2 => array:2 [ "nombre" => "Ana Tereza Orsi de" "apellidos" => "Souza" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Fundação de Dermatologia Tropical e Venereologia 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" => 972 "Ancho" => 1505 "Tamanyo" => 299240 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A), Sporangia highlighted in black with silver staining (Grocott, ×400); (B), Sporangia highlighted by PAS staining (PAS, ×400).</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 79-year-old woman, born and living in the municipality of Manaus, with non-insulin-dependent diabetes mellitus, with a pacemaker, was referred with a histopathological diagnosis of cryptococcosis, and reporting a two-year evolution of the disease.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The dermatological examination showed an ulcer on the right scapula and erythematous-papular lesions, isolated and confluent, forming small plaques, located on the left scapula (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B). Serologies were negative for HIV, syphilis, hepatitis B and C. Histopathological examination showed a granulomatous dermal infiltrate and rounded structures, isolated or grouped, of different sizes, inside histiocytes and giant cells (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A and B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">What is your diagnosis?</span><p id="par0015" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a)</span><p id="par0020" class="elsevierStylePara elsevierViewall">Cutaneous leishmaniasis</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b)</span><p id="par0025" class="elsevierStylePara elsevierViewall">Prothotecosis</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c)</span><p id="par0030" class="elsevierStylePara elsevierViewall">Cryptococcosis</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">d)</span><p id="par0035" class="elsevierStylePara elsevierViewall">Paracoccidioidomycosis</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">PAS and Grocott staining showed rounded structures and endosporulation with a morula aspect (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A and B). Analysis of the molecular structure of material obtained from culture showed the presence of <span class="elsevierStyleItalic">Prototheca wickerhamii</span>. This histopathological and molecular biology data exclude the hypotheses of cryptococcosis, leishmaniasis and paracoccidioidomycosis. The final diagnosis was protothecosis.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Protothecosis is an opportunistic disease caused by achlorophilic algae of the genus <span class="elsevierStyleItalic">Prototheca</span>, found in dogs, bats, in fresh and saltwater, sewage, soil, and cattle milk.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Humans are accidentally contaminated through skin scratches, inhalation, or ingestion of the etiological agent.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Human protothecosis is rare and occurs, in most cases, in immunocompromised patients.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In general, the clinical manifestations are predominantly cutaneous. Bursitis and systemic involvement have also been reported.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> The main agents of protothecosis are <span class="elsevierStyleItalic">Prototheca zopfii</span> and <span class="elsevierStyleItalic">P. wickerhamii</span>, with the latter being the most common.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Infiltrated plaques and ulcerated lesions are the most frequent clinical presentations.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Papular, nodular, pustular, vesicular and verrucous lesions can occur.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Clinically, all the suggested diagnostic possibilities should be considered. The hypothesis of leishmaniasis is relevant, as the patient lives in Manaus (Brazil) and this disease has been diagnosed with relative frequency in patients with no history of having left the city. Residual areas of primary and/or secondary forests are the main reservoirs of the disease in the urban area.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Paracoccidioidomycosis can cause similar clinical manifestations, but the patient had no history of activity in rural areas. This diagnosis and the hypothesis of cutaneous cryptococcosis were also ruled out through laboratory tests. The patient had no complaints or clinical evidence of systemic disease associated with protothecosis. The image exams (chest radiography and computed tomography) were normal.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The patient was treated with 200 mg/day of itraconazole. There was almost total regression of the lesions; however, the patient died due to complications from COVID-19. Itraconazole has been used for varying periods from 14 to 180 days.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> Amphotericin B is recommended for immunosuppressed patients.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0060" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors’ contributions</span><p id="par0065" class="elsevierStylePara elsevierViewall">Larissa Daniele Machado Góes: Approval of the final version of the manuscript; design and planning of the study; drafting and editing of the manuscript; collection, analysis and interpretation of data; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Vinícius da Silva Monteiro: Design and planning of the study; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Ana Tereza Orsi de Souza: Approval of the final version of the manuscript; design and planning of the study; drafting and editing of the manuscript; collection, analysis and interpretation of data; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1581942" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1423935" "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" => "2021-01-15" "fechaAceptado" => "2021-03-30" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1423935" "palabras" => array:3 [ 0 => "Infectious dermatoses" 1 => "Opportunistic infections" 2 => "Prototheca" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Protothecosis is a rare disease caused by achlorophilic algae of the genus <span class="elsevierStyleItalic">Prototheca spp</span>. In general, three clinical forms are observed: cutaneous, articular and systemic. The cutaneous form is the most common one. This study describes a patient with isolated erythematous papules and erythematous papular plaques in the scapular regions, with a previous histopathological diagnosis of cryptococcosis. New tests were conclusive for the diagnosis of protothecosis, caused by <span class="elsevierStyleItalic">Prototheca wickerhamii</span>.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Góes LDM, Monteiro VS, Souza ATO. Case for Diagnosis. Ulcer and papular lesions in a patient with diabetes mellitus. Protothecosis. An Bras Dermatol. 2021;96:613–6.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Fundação de Dermatologia Tropical e Venereologia Alfredo da Matta, Manaus, AM, Brazil.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 930 "Ancho" => 1500 "Tamanyo" => 187900 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A), Ulcerated lesion, with raised edges and an erythematous and hemorrhagic fundus. Purpuric lesions secondary to trauma; (B), Erythematous papular plaques on the scapula.</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" => 966 "Ancho" => 1505 "Tamanyo" => 338778 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A), Granulomatous dermal infiltrate consisting of lymphocytes, histiocytes, multinucleated giant cells and rounded structures, isolated or grouped, of different sizes, inside histiocytes and giant cells (Hematoxylin & eosin, ×100); (B), Greater detail of sporangia, hematoxylin-eosin staining (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" => 972 "Ancho" => 1505 "Tamanyo" => 299240 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A), Sporangia highlighted in black with silver staining (Grocott, ×400); (B), Sporangia highlighted by PAS staining (PAS, ×400).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sustained Presence of Cutaneous Leishmaniasis in Urban Manaus, the Largest Human Settlement in the Amazon" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 14 | 6 | 20 |
| 2024 October | 113 | 74 | 187 |
| 2024 September | 144 | 71 | 215 |
| 2024 August | 148 | 122 | 270 |
| 2024 July | 147 | 103 | 250 |
| 2024 June | 119 | 94 | 213 |
| 2024 May | 95 | 65 | 160 |
| 2024 April | 107 | 83 | 190 |
| 2024 March | 119 | 83 | 202 |
| 2024 February | 96 | 75 | 171 |
| 2024 January | 87 | 51 | 138 |
| 2023 December | 56 | 61 | 117 |
| 2023 November | 66 | 79 | 145 |
| 2023 October | 60 | 75 | 135 |
| 2023 September | 92 | 92 | 184 |
| 2023 August | 67 | 25 | 92 |
| 2023 July | 98 | 43 | 141 |
| 2023 June | 65 | 47 | 112 |
| 2023 May | 57 | 24 | 81 |
| 2023 April | 40 | 20 | 60 |
| 2023 March | 56 | 43 | 99 |
| 2023 February | 57 | 42 | 99 |
| 2023 January | 47 | 37 | 84 |
| 2022 December | 53 | 39 | 92 |
| 2022 November | 75 | 57 | 132 |
| 2022 October | 72 | 66 | 138 |
| 2022 September | 56 | 71 | 127 |
| 2022 August | 45 | 50 | 95 |
| 2022 July | 45 | 62 | 107 |
| 2022 June | 60 | 60 | 120 |
| 2022 May | 35 | 49 | 84 |
| 2022 April | 63 | 47 | 110 |
| 2022 March | 64 | 62 | 126 |
| 2022 February | 50 | 33 | 83 |
| 2022 January | 72 | 109 | 181 |
| 2021 December | 65 | 61 | 126 |
| 2021 November | 76 | 59 | 135 |
| 2021 October | 97 | 83 | 180 |
| 2021 September | 102 | 85 | 187 |
| 2021 August | 32 | 45 | 77 |
| 2021 July | 17 | 22 | 39 |
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