Cytomegalovirus (CMV) is the most common viral infection after transplantation. Valganciclovir (VGC) is established for prophylaxis and treatment of CMV infections, but leukopenia which appears in 10% to 13% (severe in 4.9%) is the principal side effect. We have recently noted an increased incidence of leukopenia and severe neutropenia among our renal transplant patients and thought to identify the associated factors. We conducted a retrospective analysis of all kidney transplantations performed between January 2005 and December 2006. All patients received mycophenolate mofetil (MMF), tacrolimus, and steroids. VGC was used for targeted prophylaxis and preemptive therapy of CMV infection, with doses adjusted to renal function. Of the 64 patients undergoing renal transplantation 13 (20.3%) developed leukopenia within 3 Ϯ 2 months after transplantation with severe neutropenia in 5 (7.8%). All patients were on MMF and VGC (VGC 605 Ϯ 296 mg/d). Leukopenia was significantly associated with simultaneous liver-kidney transplantation and with second kidney transplantations (P Ͻ .01). The incidence of leukopenia was higher among patients under VGC since day 1 of transplantation (P ϭ .008) with maximal incidence observed among patients prescribed 900 mg/d as opposed to those on lower doses (P Ͻ .01). There was no increase in CMV infection among patients with a low dose of VGC. No patient developed clinical CMV disease. In conclusion, VGC prophylaxis was associated with an increased frequency of leukopenia on MMF-tacrolimus treated patients or regimens. Low-dose VGC for CMV prophylaxis appeared to be as effective as high-dose treatment, and associated less frequently with leukopenia and neutropenia. C YTOMEGALOVIRUS (CMV) is a major cause of morbidity and mortality among solid organ transplant recipients.1 Among recipients of kidney transplants, CMV infection and disease are associated with decreased allograft and patient survivals.2 Risk factors for CMV infection and disease include donor (D) and recipient (R) serostatus, with donor-seropositive, recipient-seronegative (Dϩ/RϪ) as well as administration of antilymphocyte antibodies. Valganciclovir (VGC) is an L-valyl ester of ganciclovir with an oral bioavailability 10 times higher than oral ganciclovir, with the convenience of a once-daily oral dosing regimen. 4 It was recently reported that among Dϩ/RϪ patients, 900 mg/d of VGC was as clinically effective as 3 g/d of oral ganciclovir to prevent CMV.5 Several studies have reported that low-dose (450 mg/d) VGC is as effective as oral ganciclovir for CMV prophylaxis.6 -9 Present guidelines recommend 900 mg/d for CMV prophylaxis. 10Leukopenia has been the main side effect of VGC. A recent study showed that full VGC doses are associated with an important risk for neutropenia (12.5%), in conjunction with a cyclosporine (CsA)/tacrolimus-mycophenolate mofetil (MMF)-based regimen.11 In our transplant unit, in the last years we have noticed a higher incidence of leukopenia among our patients, particularly upon the introduct...

Chromoblastomycosis is one of the most frequent deep mycoses found in rural populations. This cross-sectional, retrospective and descriptive study was conducted with cases of chromoblastomycosis diagnosed throughout 20 years. A higher prevalence was observed among White male rural workers, with an average age of 59.69 years. Median time between onset of symptoms and diagnosis was 156 months. Lesions were predominantly located on the lower limbs; 34% of cases reported previous trauma. The most common associated symptoms were itching, pain and burning sensation. Mycological examination was positive in 91% of cases and Fonsecaea pedrosoi was the most prevalent etiologic agent.

We conducted a transversal retrospective study with secondary data collection from 25 cases of sporotrichosis, treated at a teaching unit in inner São Paulo (Brazil), between the years 2003-2013. We found that the prevalence was higher in men (72%), rural workers (44%) and those living in rural areas (60%), with an average age of 42.48 years. The median between the onset of lesions and diagnosis was six weeks. Lesions predominated in the upper limbs (92%), and were classified as lymphocutaneous (80%) and fixed cutaneous (20%) forms. Clinical cure was observed in 62.5% of the cases treated with potassium iodide and 100% of cases treated with itraconazole.

Incontinentia pigmenti is a rare X-linked genodermatosis that affects mainly female neonates. The first manifestation occurs in the early neonatal period and progresses through four stages: vesicular, verruciform, hyperpigmented and hypopigmented. Clinical features also manifest themselves through changes in the teeth, eyes, hair, central nervous system, bone structures, skeletal musculature and immune system. The authors report the case of a patient with cutaneous lesions and histological findings that are compatible with the vesicular stage, emphasizing the importance of early diagnosis and appropriate therapeutic management.

BackgroundRenal involvement in rheumatoid arthritis (RA) is common and has a negative impact on patient survival. Only few cases have been reported of necrotizing glomerulonephritis (GN) associated with myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA) in patients with RA.Case PresentationWe report a patient with RA who developed a necrotizing GN associated with ANCA-MPO, treated with rituximab (RTX). A 55-year-old man with a 27-year history of RA under secukinumab was referred to our nephrology clinic with worsening renal function associated with microhematuria and proteinuria. Our laboratory evaluation showed hypocomplementemia and positive titers for MPO-ANCA (615 U/mL). A renal biopsy demonstrated pauci-immune necrotizing GN. The patient was treated with 3 consecutive pulses of methylprednisolone followed by oral prednisolone (1 mg/Kg) and rituximab (1000 mg, repeated 14 days later). After a 10-month follow-up, the arthritis remains well-controlled, renal function stabilized, proteinuria improved and MPO-ANCA titer normalized (6.3 U/mL).ConclusionsNecrotizing GN is a rare but a serious condition and an early diagnosis is essential to treatment. This is the first case of necrotizing GN (without extra-renal manifestations of vasculitis) in a patient with active RA, successfully treated with RTX.