Recurrence of controlled mycosis fungoides after SARS-CoV-2 infection

nfection caused by Coronavirus 2 (Betacoronavirus genus), esponsible for the COVID-19 pandemic, can potentially ause severe acute respiratory syndrome (SARS), affect ther organs, and trigger autoimmune events as a result of he cytokine storm.1,2 Among cutaneous T-cell lymphomas CTCLs), mycosis fungoides (MF) and Sézary syndrome (SS) re the most common. MF has an indolent course, slow proression, and rarely attains a cure.1,3 The report describes he recurrence of controlled MF after SARS-CoV-2 infection nd highlights the potential immunogenic effects of the virus a positive nasal swab for SARS-CoV-2A by immunofluorescence (detection of CoV-2 nucleoproteins) was observed (COI: 94.40; COI-Cutoff Index < 1: non-reactive); D-dimer elevation (1,876 ng/mL; positive > 500 ng/mL); non-reactive serologies for human T lymphotropic viruses 1 and 2; and chest X-ray within the normal range. Skin histopathology showed lymphocytic exocytosis and cellular atypia in the epidermis (Fig. 3a-b), whereas immunohistochemistry showed the predominance of TCD4 lymphocytes and loss of expression of TCD7 lymphocytes (Fig. 3c-d). Clinical staging was established at Ib (T2bN0M0B0). The role of environmental factors and infectious agents as triggers or promoters of the development of CTCL is not yet fully established. Moreover, autoimmune disorders can generate a favorable environment for the risk of CTCL. Theories about the pathogenesis of MF and SS include

(a) Diffuse erythema and papules on the left thigh; (b) In detail, erythematous-brown follicular papules over erythema on the lateral-posterior aspect of the left trunk. a positive nasal swab for SARS-CoV-2A by immunofluorescence (detection of CoV-2 nucleoproteins) was observed (COI: 94.40; COI-Cutoff Index < 1: non-reactive); D-dimer elevation (1,876 ng/mL; positive > 500 ng/mL); non-reactive serologies for human T lymphotropic viruses 1 and 2; and chest X-ray within the normal range. Skin histopathology showed lymphocytic exocytosis and cellular atypia in the epidermis (Fig. 3a-b), whereas immunohistochemistry showed the predominance of TCD4 lymphocytes and loss of expression of TCD7 lymphocytes (Fig. 3c-d). Clinical staging was established at Ib (T2bN0M0B0).
The role of environmental factors and infectious agents as triggers or promoters of the development of CTCL is not yet fully established. Moreover, autoimmune disorders can generate a favorable environment for the risk of CTCL. Theories about the pathogenesis of MF and SS include increased Th2 activity, and reduced Th1 activity, the antitumor cytotoxic response of CD8 lymphocytes, the dendritic cell population, and the production of interleukin-12 and interferon-alpha. 2,4 The immunological dysregulation present in COVID-19 favors the reduction of the functional activity of regulatory T lymphocytes and an imbalance in the production of cytokines, in addition to the elevation of C-reactive protein and D-dimer serum levels. 5 In addition, the molecular mimicry between SARS-CoV-2 and human proteins favors the production of autoantibodies in genetically predisposed patients, causing exacerbation or emergence of autoim-  mune/autoinflammatory diseases, such as: Guillain-Barré syndrome, Kawasaki disease, immune thrombocytopenic purpura, antiphospholipid antibodies, thrombosis and, potentially, lupus erythematosus, systemic sclerosis, and pemphigus vulgaris. 4 Although most patients with indolent or controlled CTCLs are not predisposed to viral infections, conditions at risk for infection and severe symptoms of COVID-19 are considered: aggressive or advanced CTCLs, ongoing immunosuppressive therapy, lymphopenia, chronic organ failure, coexisting comorbidities, advanced age. 2 This unprecedented report of previously controlled MF, with exuberant and sudden cutaneous recurrence after SARS-CoV-2 infection, indicates viral immunogenic mechanisms as potential triggers of immune dysregulation in CTCLs.

Financial support
None declared.

Authors' contributions
Éderson Valei Lopes de Oliveira: design and planning of the case study; data collection, or analysis and interpretation of data; writing of the article or critical review of the intellectual content; collection, analysis and interpretation of data; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied case; critical review of the literature; approval of the final version of the manuscript.
Ligia Magnani Landell: collection, analysis and interpretation of data; intellectual participation in the propaedeutic conduct of the studied case; approval of the final version of the manuscript.
Cacilda da Silva Souza: design and planning of the study; analysis and interpretation of data; writing of the article or critical review of the intellectual content; collection, analysis and interpretation of data; critical review of the literature; approval of the final version of the manuscript.

Conflicts of interest
None declared.

Dear Editor,
Tricho-rhino-phalangeal syndrome (TRPS) type I is a rare condition first described by Giedion in 1966. The main characteristics are sparse and slow-growing hair, a pear-shaped nose and coned epiphyses on the medial phalanges of the hands. The hair shafts are thin and miniaturized, as in androgenetic alopecia. There is a down-regulation of the TRPS1 gene in the baldness area, and the decrease of the same pro- tein can impair endochondral cartilage differentiation and cell interactions in the development of hair follicles. 1 Short stature, Legg-Calve-Perthes Disease (aseptic necrosis of the femoral head), shortening of the toes (clinobrachydactyly), dystrophic nails, long philtrum, thin upper lip, and thinning of the distal third of the eyebrows may occur. 1,2 TRPS type I often shows an autosomal dominant pattern inheritance, but autosomal recessive inheritance can occur. Type II occurs sporadically, associated with mental retardation and multiple exostoses. 2 The aim of this study is to report the investigation of a case of TRPS in an eleven-year-old girl with mechanical arthralgia in the knees for three years, without morning stiffness, she presented also shortening of the toes and ulnar deviation of the second, third and fifth fingers, bilateral osteochondromas in the supracondylar region, hair rarefaction, and three episodes of convulsive crisis. The