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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Crusted Scabies &#40;Norwegian Scabies&#41; is a rare and severe presentation of the skin infestation caused by the mite <span class="elsevierStyleItalic">Sarcoptes scabiei</span> &#40;<span class="elsevierStyleItalic">var&#46; hominis</span>&#41; in patients with cellular immunity compromised&#46; Affected patients may present thousands of parasites on the skin surface&#46; Due to impaired immune response&#44; manifestations may occur in a atypical pattern and pruritus may be mild or absent&#44; which can lead to late diagnosis and worse prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A female 47-year-old renal transplant recipient &#40;transplant 16 years ago&#41;&#44; with chronic graft nephropathy was admitted in our hospital with asymptomatic lesions on face for one year&#46; She was taking cyclosporine&#44; mycophenolate and prednisone and was hospitalized due to acute respiratory infection and decompensation of baseline nephropathy&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">On dermatological examination&#44; she presented erythematous-scaly plaques with greyish-yellow crusts on malar regions&#44; ears&#44; dorsum nasi and supralabial region &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>a and b&#41;&#46; She denied itchiness or lesions on other areas&#46; Considering chronicity of lesions and absence of specific findings on dermoscopy&#44; we decided on performing a skin biopsy&#46; Histopathology revealed pink spiral structures adhered to the stratum corneum&#44; besides multiple mites identified as <span class="elsevierStyleItalic">S&#46; scabiei</span>&#44; and a diffuse infiltrate of eosinophils in the reticular dermis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; She was then treated with salicylate 3&#37; mineral oil and permethrin 5&#37; cream as topical therapy&#44; and oral ivermectin &#40;12<span class="elsevierStyleHsp" style=""></span>mg&#44; repeated 7 days later&#41;&#46; She showed complete improvement of lesions&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Crusted Scabies &#40;CS&#41;&#44; also known as &#8220;Norwegian Scabies&#8221; a rare and severe presentation of the skin infestation caused by the mite <span class="elsevierStyleItalic">S&#46; scabiei</span> &#40;<span class="elsevierStyleItalic">var&#46; hominis</span>&#41; that can occur in patients with cellular immunity compromised&#44; including those with graft-<span class="elsevierStyleItalic">versus</span>-host disease&#44; HIV-AIDS&#44; and those ones taking corticosteroids or other immunosuppressants&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;2</span></a> In this particular presentation&#44; mites reproduce more effectively so that affected patients may carry thousands of parasites over the skin surface&#46; It is highly contagious and minimal contact may be enough to lead to infection&#46; Due to impaired cellular immune response&#44; those patients may present atypical manifestations and pruritus may be mild or even absent&#44; so that diagnosis can be challenging&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">CS differs from classic Scabies&#59; it manifests as hyperkeratosis&#44; especially on acral sites&#44; but may be disseminated&#46; It may also presents as crusts with erythematous base and lamellar scaling in areas such as scalp&#44; face and neck&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;6</span></a> Secondary bacterial infection may occur&#44; which increases the risk of bacteremia and sepsis&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> Besides the suggestive clinic&#44; diagnosis of CS can be assisted by dermoscopy and microscopy&#44; which allow the direct visualization <span class="elsevierStyleItalic">in vivo</span> of mites and eggs&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> Skin biopsy may confirm the diagnosis if it contains mites or eggs&#46; However&#44; clinical diagnosis may be challenging due to atypical presentation added up with mild or absent pruritus&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> In this case&#44; our patient had long-term lesions&#44; with exclusive facial involvement and complete absence of pruritus&#46; On dermoscopic examination&#44; features were not suggestive of scabies&#44; so histopathology ended up confirming the diagnosis&#46; Treatment of immunosuppressed patients with CS should combine topical permethrin with systemic ivermectin &#40;repeated in 7&#8211;15 days&#41;&#46; In addition&#44; patient isolation and behavioural measures are necessary to prevent dissemination&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Early diagnosis and treatment reduce the risk of transmission&#44; outbreaks and severe evolution with associated bacterial infection&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> The main differential diagnosis must be done with crusted demodicidosis&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Thus&#44; atypical manifestations of scabies&#44; especially in immunocompromised patients&#44; should be considered&#44; and direct microscopy and&#47;or histopathology may be the key for the right diagnosis&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Declarations</span><p id="par0040" class="elsevierStylePara elsevierViewall">Informed consent to publish individual data was obtained from the patient&#46;</p></span></span>"
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Letter to the Editor
Facial crusted scabies on renal transplant patient
Sarna costrosa facial en paciente con trasplante renal
Fernanda Poy Dondonis
Autor para correspondencia
fdondonis@hcpa.edu.br

Corresponding author.
, Daniel Martins Costa Jappur, Gabriel Challub Pires, André da Silva Cartell, Renan Rangel Bonamigo
Dermatology Service of Hospital de Clínicas de Porto Alegre/Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Crusted Scabies &#40;Norwegian Scabies&#41; is a rare and severe presentation of the skin infestation caused by the mite <span class="elsevierStyleItalic">Sarcoptes scabiei</span> &#40;<span class="elsevierStyleItalic">var&#46; hominis</span>&#41; in patients with cellular immunity compromised&#46; Affected patients may present thousands of parasites on the skin surface&#46; Due to impaired immune response&#44; manifestations may occur in a atypical pattern and pruritus may be mild or absent&#44; which can lead to late diagnosis and worse prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A female 47-year-old renal transplant recipient &#40;transplant 16 years ago&#41;&#44; with chronic graft nephropathy was admitted in our hospital with asymptomatic lesions on face for one year&#46; She was taking cyclosporine&#44; mycophenolate and prednisone and was hospitalized due to acute respiratory infection and decompensation of baseline nephropathy&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">On dermatological examination&#44; she presented erythematous-scaly plaques with greyish-yellow crusts on malar regions&#44; ears&#44; dorsum nasi and supralabial region &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>a and b&#41;&#46; She denied itchiness or lesions on other areas&#46; Considering chronicity of lesions and absence of specific findings on dermoscopy&#44; we decided on performing a skin biopsy&#46; Histopathology revealed pink spiral structures adhered to the stratum corneum&#44; besides multiple mites identified as <span class="elsevierStyleItalic">S&#46; scabiei</span>&#44; and a diffuse infiltrate of eosinophils in the reticular dermis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; She was then treated with salicylate 3&#37; mineral oil and permethrin 5&#37; cream as topical therapy&#44; and oral ivermectin &#40;12<span class="elsevierStyleHsp" style=""></span>mg&#44; repeated 7 days later&#41;&#46; She showed complete improvement of lesions&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Crusted Scabies &#40;CS&#41;&#44; also known as &#8220;Norwegian Scabies&#8221; a rare and severe presentation of the skin infestation caused by the mite <span class="elsevierStyleItalic">S&#46; scabiei</span> &#40;<span class="elsevierStyleItalic">var&#46; hominis</span>&#41; that can occur in patients with cellular immunity compromised&#44; including those with graft-<span class="elsevierStyleItalic">versus</span>-host disease&#44; HIV-AIDS&#44; and those ones taking corticosteroids or other immunosuppressants&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;2</span></a> In this particular presentation&#44; mites reproduce more effectively so that affected patients may carry thousands of parasites over the skin surface&#46; It is highly contagious and minimal contact may be enough to lead to infection&#46; Due to impaired cellular immune response&#44; those patients may present atypical manifestations and pruritus may be mild or even absent&#44; so that diagnosis can be challenging&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">CS differs from classic Scabies&#59; it manifests as hyperkeratosis&#44; especially on acral sites&#44; but may be disseminated&#46; It may also presents as crusts with erythematous base and lamellar scaling in areas such as scalp&#44; face and neck&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;6</span></a> Secondary bacterial infection may occur&#44; which increases the risk of bacteremia and sepsis&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> Besides the suggestive clinic&#44; diagnosis of CS can be assisted by dermoscopy and microscopy&#44; which allow the direct visualization <span class="elsevierStyleItalic">in vivo</span> of mites and eggs&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> Skin biopsy may confirm the diagnosis if it contains mites or eggs&#46; However&#44; clinical diagnosis may be challenging due to atypical presentation added up with mild or absent pruritus&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> In this case&#44; our patient had long-term lesions&#44; with exclusive facial involvement and complete absence of pruritus&#46; On dermoscopic examination&#44; features were not suggestive of scabies&#44; so histopathology ended up confirming the diagnosis&#46; Treatment of immunosuppressed patients with CS should combine topical permethrin with systemic ivermectin &#40;repeated in 7&#8211;15 days&#41;&#46; In addition&#44; patient isolation and behavioural measures are necessary to prevent dissemination&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Early diagnosis and treatment reduce the risk of transmission&#44; outbreaks and severe evolution with associated bacterial infection&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> The main differential diagnosis must be done with crusted demodicidosis&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Thus&#44; atypical manifestations of scabies&#44; especially in immunocompromised patients&#44; should be considered&#44; and direct microscopy and&#47;or histopathology may be the key for the right diagnosis&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Declarations</span><p id="par0040" class="elsevierStylePara elsevierViewall">Informed consent to publish individual data was obtained from the patient&#46;</p></span></span>"
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