Millipede accident with unusual dermatological lesion☆☆☆

Statins have been widely used because of their effect on ering blood cholesterol and for having a well-established e in preventing cardiovascular and cerebrovascular ents. They also has an immunomodulatory effect on the gative regulation of MHCII expression. There is a shift from 1 (T helper cells) to Th2, which leads to the increase B cells, activating the excessive production of antibod, besides exerting an inhibitory effect on natural killer lls (NKs), which are crucial for natural immunity against racellular pathogens, thus compromising immune vigice against viral infections and predisposing to tumor cell liferation.5 Hence, it is possible to infer that statins predispose to lyomaviridae infection and the consequent proliferation MCC tumor cells, a phenomenon similar as that occurring th the immunocompromised. Conflicts of interest

Statins have been widely used because of their effect on lowering blood cholesterol and for having a well-established role in preventing cardiovascular and cerebrovascular events. They also has an immunomodulatory effect on the negative regulation of MHCII expression. There is a shift from Th1 (T helper cells) to Th2, which leads to the increase of B cells, activating the excessive production of antibodies, besides exerting an inhibitory effect on natural killer cells (NKs), which are crucial for natural immunity against intracellular pathogens, thus compromising immune vigilance against viral infections and predisposing to tumor cell proliferation. 5 Hence, it is possible to infer that statins predispose to Polyomaviridae infection and the consequent proliferation of MCC tumor cells, a phenomenon similar as that occurring with the immunocompromised.
Because of the rarity of the tumor, there is currently no standard consensus for treatment. One recommendation is broad surgical excision with free margins of 2 cm and adjuvant or isolated radiotherapy. 5 We report a case of MCC in an immunocompetent patient with a diagnosis below the average age of those diagnosed with MCC, with no history of other skin cancers, and a chronic statin user, thus strengthening the correlation between MCC and statin use.

Financial support
None declared.

Author's contributions
Isaura Azevedo Fasciani: Elaboration and writing of the manuscript.
Luisa Groba Bandeira: Obtaining, analyzing and interpreting the data; critical review of the manuscript.
Neusa Yuriko Sakai Valente: Approval of the final version of the manuscript; effective participation in research orientation; critical review of the literature; critical review of the manuscript.
Maria Fernanda Vieira Cunha Camargo: Conception and planning of the study; obtaining, analyzing and interpreting the data; critical review of the literature. tion and no other symptoms, and that he saw a millipede on the bed (Figs. 1---3). He went to the emergency room, where he was treated with antihistamines. Due to a lack of improvement, he sought a dermatologist. At the physical examination, the patient presented three spiral-shaped erythematous brownish spots, measuring approximately 3 cm each, located on the anterolateral surface of the right thigh. Clobetasol 0.05% ointment was prescribed, leading to an improvement of the burning sensation of the lesions.

Conflicts of interest
Millipedes are animals of the phylum Arthropoda, the group with the largest number of invertebrate species. A member of the Diplopoda class, they have a cylindrical, segmented, rigid exoskeleton and two pairs of appendages or limbs (myriads) articulated in each segment, which move   symmetrically and slowly, unlike centipedes (Chilopoda), which have only one pair of limbs per segment for support and thrust, giving them faster movement. 1 Millipedes are nocturnal animals that inhabit dark and humid places, and have two defense mechanisms: spiral curling (with the head in the center), providing greater resistance to the exoskeleton, and the discharge of an irritating secretion, which flows from glands on the lateral portion of each body segment when the animal is under threat or being crushed. The secretion can also be ejected from a distance. 2,3 The species related to human accidents in Brazil, Rhinocricus padbergi (family Rhinocricidae), is a member of the Spirobolida order, whose secretion is mainly composed of benzoquinone (2-methyl-1,4-benzoquinone), a highly irritating compound. 2 These are mostly harmless animals; however, when defending themselves, they can excrete toxins that cause irritating and pigmenting chemical reactions in the skin. 3,4 Accidents with children and adults usually occur when they are unconscious, lying on the floor, or during contact with clothes and shoes, especially during the rainy season, when millipedes invade urban areas and houses in search of shelter in a dark place. 5 Almost immediately after contact, there is numbness and a burning sensation on the skin. 4 The affected site becomes erythematous, with initially brownish-yellow pigmentation, darkening after 24 h and turning reddish-brown to black, with a cyanotic appearance, a coloration that may persist for several months. 3 Depending on the amount of secretion and exposure time, the pigmented lesion may dry out and peel in approximately seven days, or there may be blistering that, upon rupture, leaves the surface eroded. 2 Most case reports describe pigmented lesions without a definite shape resulting from crushing the millipede. The present case is particularly interesting because the lesions reproduced the body shape of the millipede, in the defensive position, as an impression of the animal on the skin, mirroring the position of the secretory glands.

Financial support
None declared.

Authors' contribution
Silmara Navarro Pennini: Conception and planning of the study; preparation and writing of the manuscript; intellectual participation in propaedeutic and/or therapeutic conduct of the studied case.
Paula Frassinetti Bessa Rebello: Preparation and writing of the manuscript; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases; critical review of the literature.
Maria das Graças Vale Barbosa Guerra: Preparation and writing of the manuscript; critical review of the literature; critical revision of the manuscript.
Sinésio Talhari: Approval of the final version of the manuscript; participation in the study design and planning; critical revision of the manuscript.