RESUMEN
Previous American Telemedicine Association (ATA) Teledermatology Practice Guidelines were issued in 2007. This updated version reflects new knowledge in the field, new technologies, and the need to incorporate teledermatology practice in a variety of settings, including hospitals, urgent care centers, Federally Qualified Health Centers, school-based clinics, public health facilities, and patient homes.
Asunto(s)
Dermatología/organización & administración , Guías de Práctica Clínica como Asunto , Telemedicina/organización & administración , Acreditación/normas , Confidencialidad/normas , Continuidad de la Atención al Paciente/normas , Dermatología/normas , Urgencias Médicas , Accesibilidad a los Servicios de Salud/normas , Humanos , Calidad de la Atención de Salud/normas , Derivación y Consulta/normas , Telemedicina/normas , Estados UnidosRESUMEN
Leprosy, or Hansen disease, is an infection that affects the mucous membranes of the respiratory tract and may manifest with nasal symptoms of chronic rhinitis, including nasal congestion, rhinorrhea, and intermittent epistaxis. We present a case of a woman diagnosed with leprosy as an incidental finding from a biopsy obtained during endoscopic sinus surgery for the management of chronic rhinitis. The diagnosis of leprosy should be considered in patients with nasal symptoms and presumptive chronic rhinitis who do not respond adequately to standard therapies.
Asunto(s)
Lepra Dimorfa/diagnóstico , Lepra Lepromatosa/diagnóstico , Rinitis/microbiología , Rinitis/patología , Adulto , Biopsia , Enfermedad Crónica , Femenino , Humanos , Lepra Dimorfa/complicaciones , Lepra Dimorfa/tratamiento farmacológico , Lepra Lepromatosa/complicaciones , Lepra Lepromatosa/tratamiento farmacológico , Rinitis/cirugíaRESUMEN
Lepromatous leprosy is a model of immune evasion wherein pathogen-specific IL-10-secreting T cells and concomitant failure of Th-1 immunity permit uncontrolled proliferation of the intracellular pathogen, Mycobacterium leprae (M. leprae). The mechanism of this immune escape is unknown. Here, the authors report that phenolic glycolipid-1 (PGL-1), a major and distinguishing feature of the M. leprae cell wall, is expressed in the cell membrane of M. leprae-infected human dendritic cells, where it can activate complement in human serum. The authors demonstrate that PGL-1 and the C3 component of complement colocalize in lipid rafts in the dendritic cell membrane, and enter the immune synapse upon co-culture of M. leprae-infected DCs and T cells. Hence, activated C3 is strategically located to costimulate naïve T cells via the complement regulatory protein, CD46, a process known to stimulate the differentiation of IL-10-secreting regulatory T cells. These observations suggest a potential novel mechanism of immune evasion, wherein M. leprae may subvert host natural immunity to provoke an adaptive response that favors bacillary survival.
Asunto(s)
Lepra/inmunología , Mycobacterium leprae/inmunología , Inmunidad Adaptativa , Antígenos Bacterianos/metabolismo , Activación de Complemento , Complemento C3/inmunología , Células Dendríticas/inmunología , Células Dendríticas/metabolismo , Células Dendríticas/microbiología , Glucolípidos/metabolismo , Humanos , Interleucina-10/metabolismo , Mycobacterium leprae/metabolismo , Linfocitos T/inmunologíaRESUMEN
Neutrophil recruitment is pivotal to the host defense against microbial infection, but it also contributes to the immunopathology of disease. We investigated the mechanism of neutrophil recruitment in human infectious disease by means of bioinformatic pathways analysis of the gene expression profiles in the skin lesions of leprosy. In erythema nodosum leprosum (ENL), which occurs in patients with lepromatous leprosy and is characterized by neutrophil infiltration in lesions, the most overrepresented biological functional group was cell movement, including E-selectin, which was coordinately regulated with interleukin 1beta (IL-1beta). In vitro activation of Toll-like receptor 2 (TLR2), up-regulated in ENL lesions, triggered induction of IL-1beta, which together with interferon gamma induced E-selectin expression on and neutrophil adhesion to endothelial cells. Thalidomide, an effective treatment for ENL, inhibited this neutrophil recruitment pathway. The gene expression profile of ENL lesions comprised an integrated pathway of TLR2 and Fc receptor activation, neutrophil migration, and inflammation, providing insight into mechanisms of neutrophil recruitment in human infectious disease.
Asunto(s)
Lepra/inmunología , Infiltración Neutrófila/inmunología , Análisis por Conglomerados , Selectina E/biosíntesis , Selectina E/genética , Selectina E/inmunología , Perfilación de la Expresión Génica , Humanos , Inflamación/inmunología , Interferón gamma/biosíntesis , Interferón gamma/genética , Interferón gamma/inmunología , Interleucina-1beta/biosíntesis , Interleucina-1beta/genética , Interleucina-1beta/inmunología , Lepra/genética , Modelos Biológicos , Mycobacterium lepraemurium/aislamiento & purificación , Infiltración Neutrófila/efectos de los fármacos , Infiltración Neutrófila/genética , Análisis de Secuencia por Matrices de Oligonucleótidos , Receptores Fc/biosíntesis , Receptores Fc/genética , Receptores Fc/inmunología , Transducción de Señal/efectos de los fármacos , Piel/inmunología , Piel/microbiología , Talidomida/farmacología , Receptor Toll-Like 2/biosíntesis , Receptor Toll-Like 2/genética , Receptor Toll-Like 2/inmunologíaRESUMEN
Telemedicine programs provide specialty health services to remote populations using telecommunications technology. This innovative approach to medical care delivery has been expanding for several years and currently covers various specialty areas such as cardiology, dermatology, and pediatrics. Economic evaluations of telemedicine, however, remain rare, and few of those conducted have accounted for the wide range of economic costs and benefits. Rigorous benefit-cost analyses of telemedicine programs could provide credible and comparative evidence of their economic viability and thus lead to the adoption and/or expansion of the most successful programs. To facilitate more advanced economic evaluations, this article presents research guidelines for conducting benefit-cost analyses of telemedicine programs, emphasizing opportunity cost estimation, commonly used program outcomes, and monetary conversion factors to translate outcomes to dollar values. The article concludes with specific recommendations for future research.
Asunto(s)
Análisis Costo-Beneficio/métodos , Guías como Asunto , Telemedicina/economía , Literatura de Revisión como AsuntoRESUMEN
Effective innate immunity against many microbial pathogens requires macrophage programs that upregulate phagocytosis and direct antimicrobial pathways, two functions generally assumed to be coordinately regulated. We investigated the regulation of these key functions in human blood-derived macrophages. Interleukin-10 (IL-10) induced the phagocytic pathway, including the C-type lectin CD209 and scavenger receptors, resulting in phagocytosis of mycobacteria and oxidized low-density lipoprotein. IL-15 induced the vitamin D-dependent antimicrobial pathway and CD209, yet the cells were less phagocytic. The differential regulation of macrophage functional programs was confirmed by analysis of leprosy lesions: the macrophage phagocytosis pathway was prominent in the clinically progressive, multibacillary form of the disease, whereas the vitamin D-dependent antimicrobial pathway predominated in the self-limited form and in patients undergoing reversal reactions from the multibacillary to the self-limited form. These data indicate that macrophage programs for phagocytosis and antimicrobial responses are distinct and differentially regulated in innate immunity to bacterial infections.
Asunto(s)
Lepra/inmunología , Macrófagos/inmunología , Viabilidad Microbiana , Mycobacterium leprae/inmunología , Mycobacterium leprae/fisiología , Fagocitosis , Perfilación de la Expresión Génica , Regulación de la Expresión Génica , Humanos , Interleucina-10/inmunología , Interleucina-15/inmunologíaRESUMEN
The repertoires of CD1- and MHC-restricted T cells are complementary, permitting the immune recognition of both lipid and peptide Ags, respectively. To compare the breadth of the CD1-restricted and MHC-restricted T cell repertoires, we evaluated T cell responses against lipid and peptide Ags of mycobacteria in leprosy, comparing tuberculoid patients, who are able to restrict the pathogen, and lepromatous patients, who have disseminated infection. The striking finding was that in lepromatous leprosy, T cells did not efficiently recognize lipid Ags from the leprosy pathogen, Mycobacterium leprae, or the related species, Mycobacterium tuberculosis, yet were able to efficiently recognize peptide Ags from M. tuberculosis, but not M. leprae. To identify a mechanism for T cell unresponsiveness against mycobacterial lipid Ags in lepromatous patients, we used T cell clones to probe the species specificity of the Ags recognized. We found that the majority of M. leprae-reactive CD1-restricted T cell clones (92%) were cross-reactive for multiple mycobacterial species, whereas the majority of M. leprae-reactive MHC-restricted T cells were species specific (66%), with a limited number of T cell clones cross-reactive (34%) with M. tuberculosis. In comparison with the MHC class II-restricted T cell repertoire, the CD1-restricted T cell repertoire is limited to recognition of cross-reactive Ags, imparting a distinct role in the host response to immunologically related pathogens.
Asunto(s)
Antígenos CD1/inmunología , Antígenos de Histocompatibilidad Clase II/metabolismo , Mycobacterium leprae/inmunología , Mycobacterium tuberculosis/inmunología , Receptores de Antígenos de Linfocitos T/biosíntesis , Subgrupos de Linfocitos T/inmunología , Subgrupos de Linfocitos T/metabolismo , Adulto , Anciano , Presentación de Antígeno , Antígenos CD1/sangre , Antígenos CD1/metabolismo , Línea Celular , Células Cultivadas , Células Dendríticas/inmunología , Células Dendríticas/metabolismo , Epítopos de Linfocito T/inmunología , Epítopos de Linfocito T/metabolismo , Femenino , Antígenos de Histocompatibilidad Clase II/inmunología , Humanos , Lepra Lepromatosa/inmunología , Lepra Lepromatosa/microbiología , Lípidos/inmunología , Recuento de Linfocitos , Masculino , Persona de Mediana Edad , Monocitos/inmunología , Monocitos/metabolismo , Subgrupos de Linfocitos T/microbiología , Subgrupos de Linfocitos T/patología , Células Th2/inmunología , Células Th2/metabolismo , Tuberculosis/inmunología , Tuberculosis/microbiologíaAsunto(s)
Eritema Nudoso/tratamiento farmacológico , Hipersensibilidad Tardía/tratamiento farmacológico , Inmunosupresores/uso terapéutico , Lepra Dimorfa/inmunología , Lepra Lepromatosa/inmunología , Ácido Micofenólico/análogos & derivados , Adulto , Quimioterapia Combinada , Eritema Nudoso/etiología , Femenino , Humanos , Hipersensibilidad Tardía/etiología , Masculino , Persona de Mediana Edad , Ácido Micofenólico/uso terapéuticoRESUMEN
Langerhans cells (LCs) constitute a subset of DCs that initiate immune responses in skin. Using leprosy as a model, we investigated whether expression of CD1a and langerin, an LC-specific C-type lectin, imparts a specific functional role to LCs. LC-like DCs and freshly isolated epidermal LCs presented nonpeptide antigens of Mycobacterium leprae to T cell clones derived from a leprosy patient in a CD1a-restricted and langerin-dependent manner. LC-like DCs were more efficient at CD1a-restricted antigen presentation than monocyte-derived DCs. LCs in leprosy lesions coexpress CD1a and langerin, placing LCs in position to efficiently present a subset of antigens to T cells as part of the host response to human infectious disease.
Asunto(s)
Presentación de Antígeno , Antígenos CD1/fisiología , Antígenos de Superficie/fisiología , Células de Langerhans/fisiología , Lectinas Tipo C/fisiología , Lectinas de Unión a Manosa/fisiología , Linfocitos T/metabolismo , Antígenos CD , Antígenos CD1/metabolismo , Antígenos de Superficie/metabolismo , División Celular , Relación Dosis-Respuesta a Droga , Epidermis/inmunología , Sangre Fetal/metabolismo , Humanos , Inmunohistoquímica , Células de Langerhans/metabolismo , Lectinas/química , Lectinas Tipo C/metabolismo , Lepra/inmunología , Lectinas de Unión a Manosa/metabolismo , Microscopía Fluorescente , Mycobacterium leprae/metabolismo , Fenotipo , Receptores de Antígenos/químicaRESUMEN
"Polymastia" is a term used to describe the presence of more than 2 breasts in human beings. It is synonymous with supernumerary or accessory breast tissue. Accessory breast tissue has the potential to undergo the same benign and malignant changes as normal pectoral breast tissue.
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Mama/anomalías , Adulto , Axila , Femenino , Humanos , Persona de Mediana EdadRESUMEN
Leprosy presents as a clinical and immunological spectrum of disease. With the use of gene expression profiling, we observed that a distinction in gene expression correlates with and accurately classifies the clinical form of the disease. Genes belonging to the leukocyte immunoglobulin-like receptor (LIR) family were significantly up-regulated in lesions of lepromatous patients suffering from the disseminated form of the infection. In functional studies, LIR-7 suppressed innate host defense mechanisms by shifting monocyte production from interleukin-12 toward interleukin-10 and by blocking antimicrobial activity triggered by Toll-like receptors. Gene expression profiles may be useful in defining clinical forms of disease and providing insights into the regulation of immune responses to pathogens.
Asunto(s)
Perfilación de la Expresión Génica , Regulación de la Expresión Génica , Lepra Lepromatosa/clasificación , Lepra Lepromatosa/genética , Lepra Tuberculoide/clasificación , Lepra Tuberculoide/genética , Algoritmos , Análisis por Conglomerados , Recuento de Colonia Microbiana , Citocinas/genética , Citocinas/metabolismo , Genes de Inmunoglobulinas , Humanos , Inmunidad Celular , Inmunidad Innata , Lepra Lepromatosa/inmunología , Lepra Lepromatosa/fisiopatología , Lepra Tuberculoide/inmunología , Lepra Tuberculoide/fisiopatología , Macrófagos Alveolares/microbiología , Glicoproteínas de Membrana/inmunología , Mycobacterium tuberculosis/crecimiento & desarrollo , Mycobacterium tuberculosis/inmunología , Análisis de Secuencia por Matrices de Oligonucleótidos , Reacción en Cadena de la Polimerasa , Análisis de Componente Principal , Receptores de Superficie Celular/inmunología , Receptores Inmunológicos/genética , Receptores Inmunológicos/metabolismo , Receptores Toll-Like , Regulación hacia ArribaRESUMEN
Leprosy presents as a clinical and immunological spectrum of disease. With the use of gene expression profiling, we observed that a distinction in gene expression correlates with and accurately classifies the clinical form of the disease. Genes belonging to the leukocyte immunoglobulin-like receptor (LIR) family were significantly up-regulated in lesions of lepromatous patients suffering from the disseminated form of the infection. In functional studies, LIR-7 suppressed innate host defense mechanisms by shifting monocyte production from interleukin-12 toward interleukin-10 and by blocking antimicrobial activity triggered by Toll-like receptors. Gene expression profiles may be useful in defining clinical forms of disease and providing insights into the regulation of immune responses to pathogens.
Asunto(s)
Humanos , Análisis por Conglomerados , Citocinas/genética , Citocinas/metabolismo , Recuento de Colonia Microbiana , Glicoproteínas de Membrana/inmunología , Lepra Tuberculoide/clasificación , Lepra Tuberculoide/fisiopatología , Lepra Tuberculoide/genética , Lepra Tuberculoide/inmunología , Lepra Lepromatosa/clasificación , Lepra Lepromatosa/fisiopatología , Lepra Lepromatosa/genética , Lepra Lepromatosa/inmunología , Inmunidad Celular , Inmunidad Innata , Macrófagos Alveolares/microbiología , Mycobacterium tuberculosis/crecimiento & desarrollo , Mycobacterium tuberculosis/inmunología , Perfilación de la Expresión Génica , Reacción en Cadena de la Polimerasa , Receptores Inmunológicos/genética , Receptores Inmunológicos/metabolismo , Receptores de Superficie Celular/inmunología , Regulación de la Expresión Génica , Algoritmos , Análisis de Componente Principal , Análisis de Secuencia por Matrices de Oligonucleótidos , Genes de Inmunoglobulinas , Regulación hacia ArribaRESUMEN
Necrobiotic xanthogranuloma (NXG) is a disorder characterized by indurated, yellow-red nodules or plaques, primarily involving the face and, less frequently, the trunk and extremities. NXG may be associated with paraproteinemia, multiple myeloma, and hypertension. Histologically, xanthogranulomatous features with hyaline necrosis or necrobiosis are present. No first-line treatment has been established. This disease is a chronic process, and a patient's prognosis depends on the degree of extracutaneous involvement and the presence of visceral malignancies. We describe a patient with typical cutaneous and histologic findings of NXG with an associated monoclonal gammopathy.
Asunto(s)
Granuloma/patología , Gammopatía Monoclonal de Relevancia Indeterminada/patología , Trastornos Necrobióticos/patología , Xantomatosis/patología , Biopsia con Aguja , Femenino , Estudios de Seguimiento , Granuloma/complicaciones , Humanos , Inmunohistoquímica , Persona de Mediana Edad , Gammopatía Monoclonal de Relevancia Indeterminada/complicaciones , Trastornos Necrobióticos/complicaciones , Medición de Riesgo , Índice de Severidad de la Enfermedad , Xantomatosis/complicacionesRESUMEN
We report a rare case of concomitant Hansen's disease (HD) and sarcoidosis. Reticulin staining may be a helpful diagnostic tool in establishing the diagnosis of sarcoidosis in skin lesions. The diagnosis of HD can be established despite negative polymerase chain reaction results for the detection of Mycobacterium leprae DNA. Finally, a well-established diagnosis of sarcoidosis does not preclude the development of another granulomatous disorder. Hence, when new lesions developed in a patient with sarcoidosis despite appropriate therapy, other concurrent diagnoses should be pursued.