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RESUMEN El eritema fijo pigmentado es una toxicodermia que puede afectar la piel o las mucosas. Tiende a recurrir en las mismas localizaciones tras la administración repetida del agente desencadenante. Los principales grupos farmacológicos asociados han sidoanalgésicos, antiepilépticos y AINES. Clínicamente, hayaparición de placaseritemato-edematosas redondas u ovaladas, definidas. Existen diferentes variantes;la generalizada es una de las menos frecuentes. Se reporta el caso de un paciente de mediana edad, quien presentó un cuadro deeritema fijo pigmentadogeneralizado, asociado al uso de ARA II. Es el primer caso reportado de esta patología secundaria al uso de dicho grupo farmacológico.

SUMMARY Pigmented fixed erythema is a toxicoderma, it can affect the skin or mucous membranes. It tends to recur in the same locations after repeated administration of the triggering agent.1 The main associated pharmacological groups have been: analgesics, antiepileptics and NSAIDs. Clinically, there is the appearance of defined round or oval erythematous-edematous plaques. There are different variants, the generalized is one of the least frequent. The case of a middle-aged patient is reported, who presented a generalized fixed pigmented erythema, associated with ARBS, it is the first reported case of this pathology secondary to the use of said pharmacological group.

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Paciente varón que presentó exantema maculopapular, no pruriginoso, sin afectación palmoplantar, luego de recibir tratamiento con trimetoprim/sulfametoxazol por siete días debido a sintomatología gastrointestinal. Tras realizar historia clínica completa y con pruebas de cuarta generación se confirmó infección por VIH. Al quinto día de tratamiento antirretroviral presentó nuevas lesiones eritematosas con descamación gruesa, pruriginosas, edema facial y eosinofilia. Se realizó una biopsia de piel que reportó una dermatitis liquenoide, con espongiosis, degeneración vacuolar de la capa basal, queratinocitos necróticos e infiltrado de eosinófilos, características que favorecen la reacción por drogas. El tratamiento consistió en interrumpir la terapia combinada, uso de corticoides sistémicos, antihistamínicos y ya que, no se trató de un cuadro severo, se reinició el tratamiento antirretroviral sin complicaciones.

A male patient presented with a maculopapular, non-pruritic rash, without palmoplantar involvement, after receiving treatment with trimethoprim/sulfamethoxazole for seven days due to gastrointestinal symptoms. After taking a complete medical history and using fourth-generation tests confirmed HIV infection. On the fifth day of antiretroviral treatment, he presented new erythematous lesions with thick, pruritic scaling, facial edema and eosinophilia. A skin biopsy reported lichenoid dermatitis, with spongiosis, vacuolar degeneration of the basal layer, necrotic keratinocytes and eosinophil infiltrate, characteristics that favor drug reaction. The treatment consisted of interrupting the combined therapy, using systemic corticosteroids, antihistamines and since it was not a severe condition, antiretroviral treatment restarted without complications.

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Introduction: About 80-95% of patients infected with the human immunodeficiency virus (HIV) develop skin manifestations, which are markers of the patients' immune status. Objective: To describe the dermatologic manifestations and the clinical and sociodemographic factors of hospitalized patients diagnosed with HIV and their correlation with CD4 T-lymphocyte count. Materials and methods: We conducted an observational, cross-sectional, and retrospective study of the medical records of 227 adult patients with HIV diagnosis evaluated by dermatology in a hospital in Medellín, Colombia. Results: We included 227 patient records with 433 dermatologic manifestations, 64.4% of them infectious. The most frequent manifestations were oral candidiasis, condylomata acuminata, and drug reactions. Moreover, a statistically significant relationship was found between disseminated herpes zoster virus and secondary syphilis with a CD4 count between 200-499 cells/mm3 (p=0.04 and 0.028, respectively). There was also a statistically significant relationship between oral candidiasis and a CD4 count of less than 100 cells/mm3 (p=0.008). Conclusions: The relationship between disseminated herpes zoster with CD4 between 200-499 cells/mm3 suggests that, despite having high CD4 counts, severe forms of the disease may occur due to possible T-cell dysfunction and depletion of the immune system. Additionally, the relationship between oral candidiasis and CD4 less than 100 cells/mm3 indicates the potential role of oral candidiasis as an essential marker of weakened immune status in HIV patients.

Introducción. Entre el 80 y el 95 % de los pacientes infectados por el virus de inmunodeficiencia humana (HIV) desarrollan manifestaciones en la piel que sirven como marcadores de su estado inmunológico. Objetivos. Describir las manifestaciones dermatológicas y los factores clínicos y sociodemográficos de los pacientes hospitalizados con diagnóstico de HIV y su correlación con el recuento de linfocitos T CD4. Materiales y métodos. Se hizo un estudio observacional de corte transversal y retrospectivo a partir del registro de las historias clínicas de 227 pacientes mayores de edad con diagnóstico de HIV, evaluados por dermatología en un hospital de Medellín, Colombia. Resultados. Los 227 registros daban cuenta de 433 manifestaciones dermatológicas, el 64,4 % de ellas infecciosas. Las tres manifestaciones más frecuentes fueron candidiasis oral, condilomas acuminados y reacciones a medicamentos. Se encontró una relación estadísticamente significativa entre el virus del herpes zóster (HZ) diseminado y la sífilis secundaria, con un recuento de CD4 entre 200 y 499 células/mm3 (p=0,04 y 0,028, respectivamente), y entre la candidiasis oral y un recuento de CD4 menor de 100 células/mm3 (p=0,008). Conclusiones. La relación entre el herpes zóster diseminado y un recuento de CD4 entre 200 y 499 células/mm3 sugiere que, a pesar de los recuentos altos, se pueden presentar formas graves de la enfermedad debido a una posible disfunción de las células T y el agotamiento del sistema inmunológico. La relación entre la candidiasis oral y un recuento de CD4 menor de 100 células/mm3 plantea la posibilidad de considerar esta infección micótica como un marcador importante de debilitamiento inmunológico de los pacientes con HIV.

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RESUMEN Presentamos el caso de una paciente de 67 años con un diagnóstico clínico de reacción adversa cutánea al uso del agente quimioterapéutico citarabina, el cual recibió en el contexto del tratamiento médico por leucemia mieloide aguda. Se realiza la descripción epidemiológica, signos clínicos, evolución médica y realizamos la comparación con casos similares previamente descritos. Para excluir otros diagnósticos diferenciales se realizó estudio histopatológico y su correlación con el examen clínico.

ABSTRACT We report the case of a 67-year-old female patient with a medical diagnosis of cutaneous adverse reaction to the use of the chemotherapeutic agent cytarabine, which she received in the context of medical treatment for acute myeloid leukemia. Epidemiological description, clinical signs, medical evolution, and comparison with similar cases previously described. In order to exclude other differential diagnoses, histopathological study and its correlation with the clinical examination were performed.

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Introducción. Entre el 80 y el 95 % de los pacientes infectados por el virus de inmunodeficiencia humana (HIV) desarrollan manifestaciones en la piel que sirven como marcadores de su estado inmunológico. Objetivos. Describir las manifestaciones dermatológicas y los factores clínicos y sociodemográficos de los pacientes hospitalizados con diagnóstico de HIV y su correlación con el recuento de linfocitos T CD4. Materiales y métodos. Se hizo un estudio observacional de corte transversal y retrospectivo a partir del registro de las historias clínicas de 227 pacientes mayores de edad con diagnóstico de HIV, evaluados por dermatología en un hospital de Medellín, Colombia. Resultados. Los 227 registros daban cuenta de 433 manifestaciones dermatológicas, el 64,4 % de ellas infecciosas. Las tres manifestaciones más frecuentes fueron candidiasis oral, condilomas acuminados y reacciones a medicamentos. Se encontró una relación estadísticamente significativa entre el virus del herpes zóster (HZ) diseminado y la sífilis secundaria, con un recuento de CD4 entre 200 y 499 células/mm3 (p=0,04 y 0,028, respectivamente), y entre la candidiasis oral y un recuento de CD4 menor de 100 células/ mm3 (p=0,008). Conclusiones. La relación entre el herpes zóster diseminado y un recuento de CD4 entre 200 y 499 células/mm3 sugiere que, a pesar de los recuentos altos, se pueden presentar formas graves de la enfermedad debido a una posible disfunción de las células T y el agotamiento del sistema inmunológico. La relación entre la candidiasis oral y un recuento de CD4 menor de 100 células/mm3 plantea la posibilidad de considerar esta infección micótica como un marcador importante de debilitamiento inmunológico de los pacientes con HIV.

Introduction. About 80-95% of patients infected with the human immunodeficiency virus (HIV) develop skin manifestations, which are markers of the patients' immune status. Objective. To describe the dermatologic manifestations and the clinical and sociodemographic factors of hospitalized patients diagnosed with HIV and their correlation with CD4 T-lymphocyte count. Materials and methods. We conducted an observational, cross-sectional, and retrospective study of the medical records of 227 adult patients with HIV diagnosis evaluated by dermatology in a hospital in Medellín, Colombia. Results. We included 227 patient records with 433 dermatologic manifestations, 64.4% of them infectious. The most frequent manifestations were oral candidiasis, condylomata acuminata, and drug reactions. Moreover, a statistically significant relationship was found between disseminated herpes zoster virus and secondary syphilis with a CD4 count between 200-499 cells/mm3 (p=0.04 and 0.028, respectively). There was also a statistically significant relationship between oral candidiasis and a CD4 count of less than 100 cells/ mm3 (p=0.008). Conclusions. The relationship between disseminated herpes zoster with CD4 between 200-499 cells/mm3 suggests that, despite having high CD4 counts, severe forms of the disease may occur due to possible T-cell dysfunction and depletion of the immune system. Additionally, the relationship between oral candidiasis and CD4 less than 100 cells/mm3 indicates the potential role of oral candidiasis as an essential marker of weakened immune status in HIV patients.

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BACKGROUND: Adverse drug reactions are frequent, with cutaneous manifestations being the most common. In the hospital environment, the incidence of cutaneous drug reactions varies from 2% to 3%. OBJECTIVE: To analyze the profile of cutaneous drug reactions, relating clinical forms, suspected medications, histopathological alterations, systemic repercussions, treatment and course. METHODS: Clinical, retrospective and observational study of patients seen by the Dermatology Interconsultation team from January 2013 to December 2016. RESULTS: The frequency of cutaneous drug reactions among the evaluated patients was 13.6%, with 219 cases diagnosed. In 65.7%, the reaction was considered mild, of which the most common was exanthema, while in 34.2%, the reaction was considered severe, with DRESS being the main form of reaction(18.2%). Antibiotics (36.5%) and anticonvulsants (10%) were the most involved drugs. In addition to drug discontinuation, systemic corticosteroids were prescribed in 47% of cases and intravenous immunoglobulin (IVIg) in 4.5%. Of the mild forms, in 62%, expectant management and/or exclusive use of symptomatic treatment was used. STUDY LIMITATIONS: Retrospective study, with limitations inherent to this type of investigation; lack of some information in medical records; long evaluation period, with a possible change in external validity. CONCLUSION: The most frequently identified clinical form was exanthema, and antibiotics and anticonvulsants were the most frequently involved drug classes. About one-third of the patients had severe cutaneous drug reactions, with DRESS being the main one. Cutaneous drug reactions are frequent in clinical practice, and the dermatologist should be called in as soon as possible to assist in the diagnosis and management of these cases.

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RESUMEN Se presenta el caso de un paciente de 12 años, que 5 horas después de la aplicación de un polivalente tópico presentó aumento de volumen a nivel de pene y escroto, cursando con eritema en zonas flexurales de ingle, axila, dorso de pies y marcado eritema simétrico en nalgas con piel empastada, refiriendo intenso prurito en escala 9/10 en las lesiones. En los exámenes de laboratorio hemograma sin leucocitosis y eosinófilos 18%. Ecografía doppler testicular normal. Se indicó corticoide tópico y prednisona, con remisión de prurito y eritema siendo dado de alta a los 6 días con escasa descamación en glúteos. Por cumplir con los criterios de exposición a drogas: eritema en forma de V, compromiso flexural, ausencia de repercusión sistémica y afectación simétrica, se reportó como un exantema flexural intertriginoso simétrico relacionado a drogas (SDRIFE).

ABSTRACT The case of a 12-year-old patient is presented, who 5 hours after the application of a topical polyvalent presents an increase in volume at the level of the penis and scrotum, presenting with erythema in flexural areas of the groin, armpit, back of the feet and marked erythema symmetrical in buttocks with pasty skin, referring to intense itching on a 9/10 scale in the lesions. In laboratory tests hemogram without leukocytosis and eosinophils 18%. Normal testicular echo-Doppler. Topical corticosteroid and prednisone were indicated, with remission of pruritus and erythema, being discharged 6 days later. With little desquamation in the buttocks, due to meeting the criteria for drug exposure, V-shaped erythema, flexural compromise, absence of systemic repercussion and symmetric involvement is reported as a drug-related symmetric intertriginous flexural rash (SDRIFE).

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Abstract Background Adverse drug reactions are frequent, with cutaneous manifestations being the most common. In the hospital environment, the incidence of cutaneous drug reactions varies from 2% to 3%. Objective To analyze the profile of cutaneous drug reactions, relating clinical forms, suspected medications, histopathological alterations, systemic repercussions, treatment and course. Methods Clinical, retrospective and observational study of patients seen by the Dermatology Interconsultation team from January 2013 to December 2016. Results The frequency of cutaneous drug reactions among the evaluated patients was 13.6%, with 219 cases diagnosed. In 65.7%, the reaction was considered mild, of which the most common was exanthema, while in 34.2%, the reaction was considered severe, with DRESS being the main form of reaction(18.2%). Antibiotics (36.5%) and anticonvulsants (10%) were the most involved drugs. In addition to drug discontinuation, systemic corticosteroids were prescribed in 47% of cases and intravenous immunoglobulin (IVIg) in 4.5%. Of the mild forms, in 62%, expectant management and/or exclusive use of symptomatic treatment was used. Study limitations Retrospective study, with limitations inherent to this type of investigation; lack of some information in medical records; long evaluation period, with a possible change in external validity. Conclusion The most frequently identified clinical form was exanthema, and antibiotics and anticonvulsants were the most frequently involved drug classes. About one-third of the patients had severe cutaneous drug reactions, with DRESS being the main one. Cutaneous drug reactions are frequent in clinical practice, and the dermatologist should be called in as soon as possible to assist in the diagnosis and management of these cases.

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Abstract Introduction: Stevens-Johnson syndrome (SJS) is a rare disease that affects the skin, as well as the oral, ocular, and urogenital mucous membranes. This condition is caused by drug reactions in more than 50% of cases. Case presentation: A 20-year-old male visited the emergency service of a tertiary care hospital of Popayán due to a 10-day history of asthenia, adynamia, fever (without objective measurement records), cough with scarce whitish sputum, and headache that improved with paracetamol treatment. However, his condition worsened in the last two days, and he developed hyporexia, pharyngeal pruritus, vesicles, and blisters on the corners of the mouth, the oral mucosa, the trunk, and limbs, as well as breathing difficulty and odynophagia, prompting him to seek medical treatment at the ER. At first, disseminated herpes simplex, systemic lupus erythematosus and SJS were suspected, but based on clinical and laboratory findings, the patient was finally diagnosed with SJS with herpes simplex reactivation associated with the use paracetamol. Consequently, the administration of this drug was stopped and management with acyclovir and methylprednisolone was started. The patient progressed satisfactorily and was discharged 10 days after beginning the new treatment, and his general condition was optimal during follow-up appointments. Conclusion: The occurrence of SJS may be associated with the oral administration of paracetamol; nevertheless, its use is not discouraged due to its great overall benefits. In this sense, given that paracetamol is an over-the-counter drug widely used in Colombia, recognizing the clinical manifestations of SJS is essential to provide adequate management and avoid complications in cases such as the one reported here.

Resumen Introducción. El síndrome de Stevens-Johnson (SJS) es una enfermedad poco común que afecta la piel y las mucosas oral, ocular y urogenital; además, en más del 50% de los casos es producida por reacciones a medicamentos. Presentación del caso. Hombre de 20 años quien asistió al servicio de urgencias de un hospital de tercer nivel de Popayán (Colombia) por un cuadro clínico de 10 días de evolución consistente en astenia, adinamia, fiebre no cuantificada, tos con escasa expectoración blanquecina y cefalea, sintomatologia que mejoraba con el uso de paracetamol; sin embargo, la condición del paciente empeoró en los últimos dos días, presentando hiporexia, prurito en faringe, vesículas y ampollas en comisuras labiales, mucosa oral, tronco y extremidades, además de dificultad respiratoria y odinofagia, razón por la cual acudió al servicio. En principio de sospechó de herpes simple diseminado, lupus eritema-toso sistêmico, y SJS; sin embargo, con base en los hallazgos clínicos y de laboratorio se confirmó el diagnóstico de SJS con reactivación de herpes simple asociado a la ingesta de paracetamol, por lo que se suspendió este medicamento y se inició manejo con aciclovir y metilprednisolona. El paciente tuvo una evolución satisfactoria y fue dado de alta a los 10 días del inicio del nuevo tratamiento y en las citas de control su condición general era óptima. Conclusiones. El desarrollo de SJS puede estar asociado al consumo de paracetamol; sin embargo, su uso no se desaconseja gracias a sus grandes bondades y beneficios generales. En este sentido, dado que el paracetamol es un medicamento de venta libre y uso extenso en Colombia, es indispensable reconocer las manifestaciones clínicas del SJS para poder dar un manejo adecuado y evitar complicaciones en casos como el aquí reportado.

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ABSTRACT Background and Objectives: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are considered as a continuum of the same process. TEN or Lyell Syndrome is the most severe form. Both entities involve an acute mucocutaneous blistering reaction associated with systemic inflammation. Materials and Methods: We present a case of a young woman who developed TEN following concomitant treatment with valproate, lamotrigine, and phenobarbital. Despite the extensive mucocutaneous detachment (over 90%), prognostic evaluation was favorable (SCORTEN score 2; probability of survival 88%), and this patient evolved satisfactorily. Five days after admission, valproate was reinitiated without any subsequent adverse reaction. Results: Causality evaluation identified both lamotrigine and phenobarbital as "very probable" (ALDEN score = 6) causes and valproate as "very unlikely" (ALDEN score = 0) cause of TEN. Conclusions: SJS and TEN are true life-threatening medical emergencies. This case emphasizes the importance of early diagnosis and treatment, including the discontinuation of the causative agent, which can be lifesaving.

RESUMEN Antecedentes y objetivos: El síndrome de Stevens-Johnson (SSJ) y la necrólisis epidérmica tóxica (NET) se consideran un continuum del mismo proceso. La NET o síndrome de Lyell es la forma más grave. Ambas entidades implican una reacción ampollosa mucocutánea aguda asociada con inflamación sistémica. Materiales y métodos: Presentamos el caso de una mujer joven que desarrolló NET posterior al tratamiento concomitante con valproato, lamotrigina y fenobarbital. A pesar del extenso desprendimiento mucocutáneo (más del 90%), la evaluación pronóstica fue favorable (puntuación SCORTEN 2; probabilidad de supervivencia 88%), y esta paciente evolucionó satisfactoriamente. Cinco días después de su ingreso, se reinició el valproato sin ninguna reacción adversa posterior. Resultados: La evaluación de causalidad identificó tanto la lamotrigina como el fenobarbital como causas "muy probables" (puntuación ALDEN = 6) y el valproato como causas "muy improbables" (puntuación ALDEN = 0) de NET. Conclusiones: El SJS y la NET son verdaderas emergencias médicas potencialmente letales. Este caso enfatiza la importancia del diagnóstico y tratamiento tempranos, incluida la interrupción del agente causal, lo cual puede salvar la vida del paciente.

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ABSTRACT: Drug reactions with eosinophilia and systemic symptoms (DRESS) are rare and potentially fatal adverse hypersen-sitivity reaction to some drugs, especially anticonvulsants.The syndrome affects not only the skin but also other organs, especially the liver. The incidence can vary from 1 to 5 cases per 10.000 patients exposed to anticonvul-sants. The recognition of the syndrome is of fundamental importance since the mortality rate is between 10 and 40%. Once the diagnosis is established, the triggering drug must be identified and discontinued. Corticosteroids are usually associated with therapy. Autoimmune sequelae have been reported, including vitiligo and rarely alopecia. Alopecia universalis is a variant of alopecia areata, characterized by hair loss throughout the body. We report a case of DRESS, associated with two autoimmune dermatological diseases: alopecia universalis and vitiligo. (AU)

RESUMO: A reação a drogas com eosinofilia e sintomas sistêmicos (DRESS) é uma rara e potencialmente fatal reação adversa de hipersensibilidade, decorrente de alguns medicamentos, principalmente os anticonvulsivantes. A síndrome não afeta apenas a pele, mas também outros órgãos, principalmente o fígado. A incidência pode variar de 1 a 5 casos por 10.000 pacientes expostos aos anticonvulsivantes. O reconhecimento da síndrome é de fundamental importân-cia devido a taxa de mortalidade entre 10-40%. Uma vez estabelecido o diagnóstico, deve-se identificar o medica-mento desencadeante e suspendê-lo. O corticosteróide geralmente é associado na terapia. Sequelas autoimunes foram relatadas, incluindo vitiligo e raramente alopecia. A alopecia universal é uma variante da alopecia areata, caracterizada pela perda de pelos em todo o corpo. Relatamos um caso de DRESS, associado a duas doenças au-toimunes dermatológicas: alopecia universal e vitiligo. (AU)

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A erupção pigmentar fixa (EPF) é uma reação cutânea adversa a drogas relativamente comum, envolvendo cerca de 10% de todas as reações de hipersensibilidade a medicamentos (RHM). Envolve uma reação imunológica não imediata, mediada por células T CD8+ sensibilizadas, relacionada ao mecanismo do tipo IVc na classificação de Gell e Coombs. Um dos grupos mais frequentemente implicados nesse tipo de reação é o dos antiinflamatórios. Relatamos o caso de um homem que, 24 horas após iniciar tratamento com nimesulida para lombalgia, apresentou um quadro de lesões cutâneas tipo máculas eritemato-violáceas bem delimitadas e disseminadas pelo corpo. A nimesulida é um fármaco anti-inflamatório não esteroidal (AINE) pertencente à classe das sulfonanilidas, que atua como inibidor seletivo da enzima da síntese de prostaglandina, a ciclo-oxigenase, inibindo preferencialmente a COX-2. O diagnóstico foi comprovado pela realização do teste de contato, também conhecido como patch test, que traduziu positividade na segunda leitura realizada após 72 horas da sua colocação.

Fixed pigmented erythema (FPE) is a relatively common adverse drug reaction, consisting of approximately 10% of all drug hypersensitivity reactions. It involves a non-immediate immune reaction mediated by sensitized CD8+ T cells and related to the type IVc mechanism in the Gell-Coombs classification. One of the groups most frequently involved in this type of reaction is that of anti-inflammatory drugs. We report the case of a man who, 24 hours after starting treatment with nimesulide for low back pain, presented with well-defined cutaneous lesions consisting of erythematous-violaceous macules and spread throughout the body. Nimesulide is a non-steroidal anti-inflammatory drug (NSAID) belonging to the sulfonanilide class that acts as a selective inhibitor of the prostaglandin synthesis enzyme, cyclooxygenase (COX), preferentially inhibiting COX-2. The diagnosis was confirmed by a patch test, which translated positively in the second reading performed 72 hours after its placement.

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BACKGROUND: Little is known about the dermoscopic evaluation of cutaneous adverse drug reactions (CADRs). OBJECTIVES: To evaluate the dermoscopic patterns of CADRs and identify those associated with severe cutaneous adverse reactions to drugs (SCARDs). PATIENTS AND METHODS: Patients included in this study from May 2015 to April 2016 had presented with CADRs. CADR presentation and classification were based on standard criteria. SCARDs included Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), overlap SJS/TEN, drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalized exanthematous pustulosis (AGEP). The dermoscopic features of CADRs were described and compared according to the severity of the reactions. RESULTS: Sixty-nine patients were included. Sixteen patients (23.2%) presented SCARDs. The main dermoscopic findings in SJS, overlap SJS/TEN and TEN were black dots or necrotic areas (100%). Erosion [respectively, 4/6 (66.7%), 3/3 (100%) and 1/1 (100%)], necrotic borders [respectively, 4/6 (66.7%), 3/3 (100%) and 1/1, (100%)] and epidermal detachment [respectively, 5/6 (83.3%); 2/3 (66.7%) and 1/1 (100%)] were also common among these reactions. Erythema and purpuric dots were the main dermoscopic findings [respectively, 5/6 (83.3%) and 4/6 (66.7%)] in DRESS. In non-severe reactions, the most prevalent structures were erythema and purpura in exanthema [respectively, 31/33 (93.9%) and 24/33 (72.7%)] and erythema and vascular structures in urticarial reactions [respectively, 6/6 (100%) and 3/6 (50%)]. Black dots or necrotic areas, epidermal detachment, necrotic borders and erosion were highly associated with SCARDs (P < 0.001). CONCLUSIONS: Dermoscopy improves clinical recognition of SCARDs.

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BACKGROUND AND OBJECTIVE: Severe cutaneous adverse reactions to drugs (SCARs) are associated with high morbidity and mortality and with sequelae. Objective: To characterize patients with SCARs in 8 health care institutions in Latin America. METHODS: We performed a cross-sectional, descriptive, multicenter study of patients diagnosed with SCARs in Latin America between January 2009 and December 2018. The analysis was carried out using a database in BD Clinic. RESULTS: We collected 70 patients, of whom 42 (60%) were women. Mean age was 38.7 years. Forty-two patients (60%) had DRESS-DIHS, 12 (17.1%) TEN, 5 (7.1%) SJS, 6 (8.5%) AGEP, 4 (5.7%) other reactions not classified as SCARs, and 1 (1.4%) overlapping SJS-TEN. The main causative drugs were aromatic anticonvulsants in 31 cases (44.3%), ß-lactam antibiotics in 11 cases (15.7%), and non-ß-lactam antibiotics in 6 cases (8.6%). In all of the cases, the suspected drug was withdrawn at the first sign of a SCAR. Sixty-six patients (94.2%) received anti-inflammatory treatment, mostly systemic corticosteroids. Complications occurred in 53 cases (75.7%), and 3 patients died (4.3%). Thirteen patients (18.6%) had sequelae. CONCLUSIONS: This is the first multicenter report on SCARs in Latin America. DRESS-DIHS was the most frequently reported clinical entity, and anticonvulsants were the main triggers. Most of the patients received systemic corticosteroids. Complications were frequent, and 3 patients died.

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BACKGROUND: Anaphylaxis is a constant perioperative concern due to the exposure to several agents capable of inducing hypersensitivity reactions. Patent blue V (PBV), also known as Sulfan Blue, a synthetic dye used in sentinel node research in breast surgery, is responsible for 0.6% of reported anaphylactic conditions. We present a case of a 49-year-old female patient who underwent left breast tumorectomy with sentinel lymph node staging using PBV and experienced an anaphylactic reaction. METHODS: We conducted a literature search through PubMed for case reports, case series, reviews, and systematic reviews since 2005 with the keywords "anaphylaxis" and "patent blue". We then included articles found in these publications' reference sections. RESULTS: We found 12 relevant publications regarding this topic. The main findings are summarized, with information regarding the clinical presentation, management, and investigation protocol. Hypotension is the most common clinical manifestation. The presentation is usually delayed when compared with anaphylaxis from other agents, and cutaneous manifestations are occasionally absent. Patients may have had previous exposure to the dye, used also as a food, clothes and drug colorant. CONCLUSION: The diagnosis of anaphylaxis in patients under sedation or general anesthesia may be difficult due to particularities of the perioperative context. According to the published literature, the presentation of the reaction is similar in most cases and a heightened clinical sense is key to address the situation appropriately. Finding the agent responsible for the allergic reaction is of paramount importance to prevent future episodes.

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Abstract Background: Anaphylaxis is a constant perioperative concern due to the exposure to several agents capable of inducing hypersensitivity reactions. Patent blue V (PBV), also known as Sulfan Blue, a synthetic dye used in sentinel node research in breast surgery, is responsible for 0.6% of reported anaphylactic conditions. We present a case of a 49-year-old female patient who underwent left breast tumorectomy with sentinel lymph node staging using PBV and experienced an anaphylactic reaction. Methods: We conducted a literature search through PubMed for case reports, case series, review and systematic reviews since 2005 with the keywords "anaphylaxis" and "patent blue". We then included articles found in these publications' reference sections. Results: We found 12 relevant publications regarding this topic. The main findings are summarized, with information regarding the clinical presentation, management, and investigation protocol. Hypotension is the most common clinical manifestation. The presentation is usually delayed when compared with anaphylaxis from other agents and cutaneous manifestations are occasionally absent. Patients may have had previous exposure to the dye, used also as a food, clothes and drug colorant. Conclusion: The diagnosis of anaphylaxis in patients under sedation or general anesthesia may be difficult due to particularities of the perioperative context. According to the published literature, the presentation of the reaction is similar in most cases and a heightened clinical sense is key to address the situation appropriately. Finding the agent responsible for the allergic reaction is of paramount importance to prevent future episodes.

Resumo Introdução: A anafilaxia pode ocorrer durante o período perioperatório devido à exposição a diversos agentes capazes de induzir reações de hipersensibilidade. O corante sintético Azul Patente V (APV), também conhecido como Sulfan Blue, é usado na pesquisa de linfonodo sentinela em cirurgia de mama, e é responsável por 0,6% dos eventos anafiláticos relatados. Descrevemos o caso de uma paciente de 49 anos de idade submetida à tumorectomia de mama esquerda com estadiamento de linfonodo sentinela, em que se empregou o APV e que apresentou reação anafilática. Método: Por meio do PubMed, pesquisamos publicações que documentavam relatos de casos, séries de casos, revisões e revisões sistemáticas desde 2005, usando as palavras-chave "anaphylaxis" e "patent blue". Em seguida, incluímos artigos encontrados na lista de referências dessas publicações. Resultados: Encontramos 12 publicações relevantes sobre o tópico. Os principais achados estão resumidos, com informações do quadro clínico, tratamento e protocolo de investigação. A hipotensão foi a manifestação clínica mais frequente. De forma geral, o quadro clínico tem início tardio quando comparado à anafilaxia por outros agentes e, ocasionalmente, as manifestações cutâneas estão ausentes. Os pacientes podem ter tido exposição prévia ao APV, que também é usado como corante de alimentos, roupas e medicamentos. Conclusão: O diagnóstico de anafilaxia em pacientes sob sedação ou anestesia geral pode ser difícil devido às peculiaridades do contexto perioperatório. Segundo a literatura publicada, a apresentação da reação é semelhante na maioria dos casos e um discernimento clínico aguçado é fundamental para enfrentar o evento adequadamente. Encontrar o agente responsável pela reação alérgica é essencial para a prevenção de futuros episódios.

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A erupção fixa à droga (EFD) é uma reação de hipersensibilidade tardia a medicamentos caracterizada por máculas ou pápulas eritematosas, violáceas ou acastanhadas, bem demarcadas, que aparecem após uso de uma medicação, e reaparecem na mesma localização após exposições repetidas. A erupção fixa à droga bolhosa generalizada (EFDBG) é uma variante rara da EFD que foi recentemente incluída pelo RegiSCAR no grupo das farmacodermias graves. Apresenta-se através de lesões cutâneas generalizadas características de EFD, com formação de bolhas, geralmente em pacientes com história prévia de EFD. Os principais medicamentos envolvidos na EFDBG são antibióticos e anti-inflamatórios não esteroidais. O diagnóstico é clínico, entretanto, a biópsia cutânea na fase aguda e o teste de contato após a recuperação do paciente, podem auxiliar a investigação. O tratamento requer geralmente apenas a suspensão do fármaco suspeito e medidas de suporte. Relatamos um caso de EFDBG em adolescente após reexposição à dipirona (metamizol) apesar da história prévia de hipersensibilidade a esta medicação. O objetivo deste relato é alertar sobre a importância do diagnóstico da EFDBG e ressaltar os principais pontos para o diagnóstico diferencial com a síndrome de Stevens-Johnson (SSJ)/necrólise epidérmica tóxica (NET).

Fixed drug eruption (FDE) is a delayed drug hypersensitivity reaction characterized by erythematous, violaceous or brownish well-demarcated macules or papules that appear after use of a medication and reappear at the same site after repeated exposures. Generalized bullous fixed drug eruption (GBFDE) is a rare FDE variant that has been recently included by RegiSCAR in the group of severe cutaneous adverse reactions to drugs. GBFDE presents as generalized cutaneous lesions characteristic of FDE, with blistering, usually in patients with a previous history of FDE. The main drugs involved in GBFDE are antibiotics and nonsteroidal anti-inflammatory drugs. The diagnosis is clinical, but some tests can help the investigation, such as skin biopsy in the acute phase and patch testing after patient recovery. Treatment usually requires suspension of the suspected drug and some supportive measures. We report a case of GBFDE after reexposure to dipyrone (metamizole) in an adolescent with a previous history of hypersensitivity to this drug. The aim of this report is to warn about the importance of diagnosing GBFDE and to highlight the main points for differential diagnosis with Stevens- Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN).

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Background: Stevens-Johnson Syndrome (SSJ) and Toxic Epidermal Necrolysis (NET) are infrequent and life-threatening mucocutaneous diseases, which occur predominantly as adverse drug reactions. Aim: To describe the frequency of SSJ and NET diagnoses at a national level, estimate their incidence and describe their distribution among the different regions of the country. Material and Methods: Analysis of hospital discharge databases available at the website of the Chilean Ministry of Health searching for the tenth version of the International Classification of Diseases (ICD 10) codes for SSJ or NET, between 2001 and 2015. Results: We analyzed 24,521,796 hospital discharges nationwide. SSJ caused 855 discharges, with a lethality of 2%. NET caused 128 discharges with a lethality of 16%. The global cumulative incidence was 3.87 cases per million inhabitants per year nationwide, with a trend line to increase incidence towards the regions of higher latitude. Conclusions: SSJ and NET are dermatological emergencies with high mortality. The increase in incidence towards regions at higher latitudes may suggest an association between these conditions and lower levels of vitamin D, correlated with latitude and exposure to UV radiation.

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Abstract Topical use of immune response modifiers, such as imiquimod, has increased in dermatology. Although its topical use is well tolerated, it may be associated with exacerbations of generalized cutaneous inflammatory diseases, possibly through the systemic circulation of pro-inflammatory cytokines. This report describes a case of development of pityriasis rubra pilaris, a rare erythematous-papulosquamous dermatosis, in a woman aged 60 years during treatment with imiquimod 5% cream for actinic keratosis. It evolved with erythrodermic conditions and palmoplantar keratoderma, presenting progressive clinical resolution after the introduction of methotrexate. The authors emphasize the importance of recognizing possible systemic reactions associated with the topical use of imiquimod.

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Topical use of immune response modifiers, such as imiquimod, has increased in dermatology. Although its topical use is well tolerated, it may be associated with exacerbations of generalized cutaneous inflammatory diseases, possibly through the systemic circulation of pro-inflammatory cytokines. This report describes a case of development of pityriasis rubra pilaris, a rare erythematous-papulosquamous dermatosis, in a woman aged 60 years during treatment with imiquimod 5% cream for actinic keratosis. It evolved with erythrodermic conditions and palmoplantar keratoderma, presenting progressive clinical resolution after the introduction of methotrexate. The authors emphasize the importance of recognizing possible systemic reactions associated with the topical use of imiquimod.

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