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This article discusses common bacterial skin infections, including impetigo, cellulitis and erysipelas folliculitis, staphylococcal scalded skin syndrome, blistering distal dactylitis, furuncles and carbuncles, and pseudomonal infections such as external otitis and malignant external otitis, ecthyma gangrenosum, pseudomonal folliculitis, toe web infection, and erysipeloid.
INTRODUCTION: Cutaneous hematomas are a cause of hospitalization in departments of dermatology. Their clinical diagnosis can be difficult, particularly since they can masquerade as thrombophlebitis or abscesses. We conducted a retrospective study so as to specify their frequency, clinical aspects and circumstances of occurrence. PATIENTS AND METHODS: The search for hospitalizations was conducted, using a computer data coding and key word "hematoma", from January 1997 to March 2003. The following items were studied: age, gender, clinical aspect on admission, topography, use of anti-platelets or anticoagulants, the existence of documented overdosing, treatment before hospitalization and existence of fever. RESULTS: The 17 patients hospitalized for hematomas were 9 women and 8 men with a mean age of 71 years. Thirteen patients were treated with: antivitamin K (5 cases), low molecular weight heparin (3 cases), anti-platelets (4 cases), or a combination of antivitamin K and anti-platelets (1 case). Four patients had no antivitamin K or anti-platelet treatment; their coagulation control was normal and they were younger than the patients taking a treatment (55 versus 76 years). The hematomas always involved the lower limbs. The clinical aspect was: simple hematoma (3 cases), inflammatory or over-infected hematoma (11 cases) and post-hematoma ulceration (3 cases). Seven patients were febrile either before or during their hospitalization. A context of trauma was noted in 10 patients. In the 9 patients treated with antivitamin K or low molecular weight heparin, overdosing was documented in 5. The treatments received before hospitalization were: general antibiotherapy (7 cases), local antibiotherapy (1 case) and low molecular weight heparin (7 cases). DISCUSSION: Hematomas of the legs usually occur in elderly patients, treated with anticoagulants or anti-platelets. They present in the form of ecchymotic tumefaction, frequently inflammatory or febrile. Therapeutic overdosing is common. The ratio with the erysipelas hospitalized in our department is of 1/8; over the past 5 years we have observed a mean of 3 cases per year. Hence they are not uncommon and dermatologists must be aware of their clinical aspects and the circumstances in which they occur.
BACKGROUND: Shewanella alga is a Gram-negative bacilla often found in water or soil. Clinical infections in humans are rare, with serious infections described generally in immunocompromised hosts. CASE REPORT: A 66 year-old man with a heel wound had developed, after numerous sea baths in the Atlantic ocean (Oleron island, France), an infectious cellulitis of the leg with Shewanella alga septicemia. Despite the absence of immunodeficiency in this patient, infectious cellulitis and septicemia occurred via a wound to the skin and contact with sea water. Healing was seen after treatment with cefotaxime, ciprofoxacin and gentamicin IV, relayed with ciprofloxacin and erythromycin. Shewanella alga was also susceptible to ticarcillin, piperacillin and ceftazidime but was resistant to ampicillin, amoxicilline-clavulanate, colistin, cyclines, fosfomycin and cefsulodin. No immunological anomaly was found. DISCUSSION: We report a case of infectious cellulitis with Shewanella alga septicemia. This has not previously been described in an immunocompetent patient. Antibiotic therapy must be longer than usual treatment for streptococcal erysipelas and first-line antibiotherapy with ampicillin alone may not be sufficient.
INTRODUCTION: The aim of this retrospective study was to describe the main characteristics and treatment of male external genitalia lymphedema. PATIENTS AND METHODS: From 1987 to 2003, all patients seen in a single hospital for lymphedema of male external genitalia were included. For each patient, the following characteristics were recorded: primary or secondary lymphedema, cause of secondary form, date of onset of lymphedema, associated lower limb lymphedema, clinical signs, and complications. In the primary forms, lower limb lymphoscintigraphy was performed. Specific surgery was proposed in all cases of symptomatic lymphedema (circumcision, scrotum and/or penile cutaneous excision). RESULTS: Thirty-three patients with lymphedema of external genitalia (17 primary, 16 secondary) were recruited. Two primary lymphedema were congenital, one isolated. Mean age +/- SD of the onset of the 15 other primary genital lymphedema was 23.4 +/- 17.5 years, always after the appearance of lower limb lymphedema. Sixteen men had secondary lymphedema (bladder, prostate, or rectum cancer, Hodgkin or non-Hodgkin lymphoma, aorto-bifemoral bypass grafting, biopsy or curretage of inguinal nodes). Secondary genitalia lymphedema was not associated with lower limb lymphedema in two cases and, in the others it occurred 66 +/- 122 months after (n=11), at the same time (n=2) or before lower limb lymphedema (n=1). Clinically, we noted genitalia heaviness (n=31), lower limb lymphedema (n=30), vaginal hydrocele (n=13), impaired miction due to prepucial swelling (n=10), leakage of lymphatic fluid (n=10). Lower limb lymphedema was complicated by at least one erysipelas (n=20), spreading to the external genitalia (n=4). In primary forms, lymphoscintigraphy showed ipsilateral hypoplasia of inguinal nodes in lower limb lymphedema (n=14) and/or external genitalia backflow (n=7). Surgical treatment was performed in 17 cases (11 primary, 6 secondary) with good results after 21 months' median follow up (1 month-10 years). Two patients died of cancer. One secondary lymphedema improved spontaneously and one disappeared after withdrawal of lower limb pneumatic compression. DISCUSSION: Lymphedema of external genitalia is responsible for discomfort and local complications. Surgical treatment is the main procedure of this disorder.
BACKGROUND: Pemphigoid is a form of auto-immune bullous dermatosis characterised by the production of antibodies directed against components of hemidesmosomes in the basal membrane. The physiopathological process responsible for unmasking of these antigens is unknown. Pemphigoid is more common in elderly subjects and is most often seen in debilitated subjects. The prevalence of pemphigoid anti-pemphigoid antibodies (anti-PB) is not known in the elderly population presenting no dermatological signs evocative of the disease. We studied the prevalence of anti-PBAg2 antibodies in elderly subjects with no signs of pemphigoid as well as in the correlation between the presence of these antibodies and diagnosis of dementia. PATIENTS AND METHODS: Elderly subjects (aged over 69 years) with no signs of pemphigoid were recruited consecutively in dermatology and geriatrics departments (138 subjects). Details of concomitant medication were recorded for all subjects and clinical examination was performed with calculation of MMS (Mini Mental Score). The subjects were then divided into two groups based on MMS score. The first group comprised subjects without dementia (MMS > 24) while the second comprised subjects with dementia. Serum anti-PBAg2 antibodies were determined by ELISA and indirect immunofluorescence with confirmation by Western blot. Antinuclear antibodies, used as a control for non-specific immune response, were assayed in all serum samples. The prevalence of these antibodies was compared between the two groups. RESULTS: The two groups were comparable in terms of age, sex and presence of dermatological diseases (ulcers, bedsores, erysipelas). Each group comprised 69 subjects. The overall presence of anti-PBAg2 antibodies in subjects with no signs are suggestive of pemphigoid was 3.6%. Presence of anti-PBAg2 antibodies was associated with diagnosis of dementia (p=0.04; 0% and 7% in groups 1 and 2, respectively). No correlation was seen between the presence of anti-PBAg2 antibodies and concomitant medication or dermatological disease. The overall prevalence of antinuclear antibodies was 14.5% and the figure was similar between the two groups. DISCUSSION: The presence of anti-PBAg2 could be associated with the diagnosis of dementia in elderly subjects.
Porcine circovirus type 2 (PCV2) has been associated with a newly identified and described disease in swine called the postweaning multisystemic wasting syndrome (PMWS). An association of PCV2 with various other clinical conditions in pigs are also increasingly being reported. To date molecular studies to determine the extent of genetic variations of this virus have been limited. To more fully understand the extent of genetic diversity we report the sequencing of 34 PCV2 strains from Eastern Canada originating from a variety of clinical conditions spanning years 1990-2001 along with the phylogenetic analysis of these strains and that of 36 PCV2 sequences published in GenBank. Sequence analysis of the complete genome indicated that the Canadian PCV2 strains analyzed in the present study are closely related to each other but also to other PCV2 strains originating from Western Canada, US, Europe and Asia. Sequence analysis of ORF1 and ORF2 genes of the 34 strains revealed that the extent of nucleotide variation was greater for the ORF2 than for the ORF1. The amino acid sequences alignment of the PCV2 capsid protein identified three major regions of amino acid heterogeneity, two of which correspond with dominant immunoreactive areas. No repeatable amino acid motifs for these two regions could be associated with PCV2 strains identified from cases of PMWS or other clinical conditions. Phylogenetic analysis of all 70 strains revealed one large cluster composed of strains from Europe, Taiwan, China and Canada. This large cluster could be divided in several sub clusters, in two of which Canadian strains were found closely related to strains from Germany. The remaining strains from Canada and the US were spread in small groupings along the phylogenetic tree and an association with geographic origin could not be established. The genomic characterizations performed in this study indicate that PCV2 strains associated with PMWS are scattered throughout the phylogenetic tree often in groupings including PCV2 strains identified from cases other that PMWS such as, porcine reproductive and respiratory syndrome (PRRS), generalized tremors, porcine dermatitis and nephropathy syndrome (PDNS), arthritis, nervous signs, erysipelas and even healthy pigs.
Seven methods of serotyping of Haemophilus influenzae were evaluated. Comparing slide agglutination, staphylococcal coagglutination, latex agglutination, counterimmunoelectrophoresis, immunofluorescence, capsular swelling, and cultivation on antiserum agar the commercial coagglutination test was most reliable, most rapid, and easiest to perform. To identify all six serotypes this coagglutination test had to be combined with slide agglutination. With most methods best results were achieved by using cultures incubated at 37 degrees C for 6 h. As nonencapsulated strains often agglutinated unspecifically, selection of probably typeable strains was useful. Differentiation with help of colonial morphology and opalescent growth was facilitated by cultivation on Brain Heart Infusion (BHI) Chocolate Agar and testing of growth factor requirements on translucent BHI Agar with strips containing the growth factors V, X, and VX, respectively. In broth turbid growth was a hint for encapsulation. Nigrosin staining, a negative capsule staining, proved to be useful if specific antisera are not available. From 252 clinical isolates of H. influenzae 216 were not typeable. 36 strains could be serotyped. 27 (75%) belonged to serotype b, 6 (16.6%) were serotype e, 3 (8.3%) were serotype f. Serotype e and f were most difficult to identify. Spectrum of patients and diseases were corresponding to the findings of other authors. Less well-known infections like cellulitis (erysipelas of the cheeks) and arthritis were observed, too. Rapid identification of at least H. influenzae type b could render treatment in some cases more effective by early application of a suitable antibiotic.
Cutaneous granuloma formation distant from the gastrointestinal tract in patients with Crohn's disease of the bowel has been called metastatic Crohn's disease. We report two patients with this entity, including the first to present with an erysipelas-like eruption of the face. A review of the world's literature reveals that all patients with metastatic Crohn's disease have had gastrointestinal disease involving the colon or rectum. Clinical features of the nine previously reported cases are reviewed.
INTRODUCTION: Cutaneous metastatic Crohn's disease is a granulomatous inflammation of the skin that is noncontiguous to the gastrointestinal tract. CASE REPORT: A 42-year-old man with Crohn's disease is admitted for antibiotic resistant erysipela-like dermo-hypodermitis. The presence of granulomatous lesions on skin biopsy, the absence of any infectious agent identified despite extensive investigations and the dramatic improvement observed with corticosteroid eventually lead to the diagnosis of cutaneous metastatic Crohn's disease. CONCLUSION: During Crohn's disease, biopsy should be considered for every undiagnosed skin lesion as the characteristics of cutaneous metastatic Crohn's disease are not specific. The presence of a non caseous granulomatous dermal infiltration suggests the diagnosis and should make consider the initiation of corticosteroid and the discontinuation of others inappropriate therapeutics (i.e. surgical treatment, antibiotics).
Familial Mediterranean fever (FMF) is a recessively inherited disease of episodic fever in combination with severe abdominal pain, pleurisy, arthritis or erysipelas-like skin rashes. The disease is mainly prevalent in Sephardic Jews, Armenians, Turks and Arabs. The gene responsible for FMF was cloned in 1997. The gene expresses a protein called pyrin which is believed to play a role in the downregulation of mediators of inflammation. Several mutations have been identified of which the homozygous form of the M694V mutation is associated with a more severe expression of FMF. Prophylactic administration of colchicine is effective in relieving most patients from their attacks and preventing the development of amyloidosis, which usually leads to end-stage renal disease. Unfortunately, there is little awareness of the disease in gynaecological practice although a FMF full blown episode may mimic an acute abdominal calamity suggesting several possible gynaecological diagnoses. FMF is also associated with subfertility. In females, infertility was mainly related to oligomenorrhea although the causes remain unclear. In male FMF patients, progression of the disease may induce testicular impairment, consequently affecting spermatogenesis. Some controversy exists as to the adverse effects of colchicine on sperm production and function although the impression is that the occurrence of sperm pathology in FMF patients, using the recommended dosage of colchicine, is very low. In pregnant FMF patients, an increased occurrence of miscarriage has been found. However, the mechanisms involved remain unclear. Although colchicine is a mitotic inhibitor and transplacental crossing of colchicine has been demonstrated, no increased risk of foetal abnormalities in colchicine-treated pregnant FMF patients has been found. Therefore, amniocentesis should not be done for reassurance alone.
Familial Mediterranean fever is the best known of the recurrent hereditary autoinflammatory diseases. It predominantly affects subjects of Mediterranean origin, Sephardic Jews in particular. Its gene, MEFV, is located on chromosome 16 and has autosomal recessive transmission, with incomplete penetration. It codes for a protein called pyrin or marenostrin, which is probably involved in the inflammatory process. In most cases, the first episodes appear before the age of 20 years and very rarely after the age of 40. Episodes usually last a few days, although they may extent over several weeks when localized in joints. Fever, occasionally pseudo-malaria, may accompany various symptoms, the most frequent of which are abdominal, articular, pleural or cutaneous. The abdomen is the classic site of this disease, and acute abdominal flares masquerade as abdominal emergencies. Musculoskeletal involvement is revealed by episodes of inflammation of the joints (more often mono- than oligoarthritis) and muscle pain. The flares are usually brief and totally reversible. Flares of thoracic pain corresponding to pleural inflammation and erysipelas-like skin eruptions have been observed. Acute symptoms disappear between flares, but hepatic splenomegaly, swollen lymph nodes or abnormal fundus of the eye may persist. Laboratory findings are typical of nonspecific inflammation, accompanied by moderate hyperleukocytosis during the flares.
Erysipelothrix rhusiopathiae is the causative agent of erysipelas in animals and erysipeloid in humans. In the absence of specific antibodies, the organism evades phagocytosis by phagocytic cells, but even if phagocytized, it is able to replicate intracellulary in these cells. In this review, recent advances in our understanding of the pathogenicity of E. rhusiopathiae and its protective immunity are described.
Homeless people in developed countries have specific problems predisposing them to infectious diseases. Respiratory infections and outbreaks of tuberculosis and other aerosol transmitted infections have been reported. Homeless intravenous drug users are at an increased risk of contracting HIV, and hepatitis B and C infections. Skin problems are the main reason the homeless seek medical attention, and these commonly include scabies, pediculosis, tinea infections, and impetigo. Many foot disorders are more prevalent in the homeless including ulcers, cellulitis, erysipelas, and gas gangrene. The louse transmitted bacteria Bartonella quintana has recently been found to cause clinical conditions in the homeless such as urban trench fever, bacillary angiomatosis, endocarditis, and chronic afebrile bacteraemia. Treatment of homeless people is complicated by financial constraints, self-neglect, and lack of adherence. Patients with serious and contagious illnesses should be hospitalised. Physicians should be aware of these specific issues to enhance care.
BACKGROUND: Pseudomembranous fat necrosis is a peculiar manifestation of necrosis of adipose tissue characterized by formation of pseudocystic cavities lined by crenulated membranes. The underlying mechanism for the formation of pseudomembranes is unknown and numerous hypotheses have been proposed. Despite divergent interpretations, most authors consider necrotic fat cells to be the anatomic substrate for the formation of pseudomembranes. METHODS: A total of 341 panniculitides were reviewed for the presence of pseudomembranous fat necrosis. The specific diagnoses were established after correlation of all available clinical and laboratory data with the histopathology. Special attention was given to the time in the evolution of the disease when the biopsy was taken. Additional immunohistochemical studies were performed in 12 cases. RESULTS: Thirty of 341 cases of different types of panniculitides were found to show pseudomembranous fat necrosis, namely: 10 of 15 cases of sclerosing panniculitis (lipodermatosclerosis), 6 of 95 cases of erythema nodosum, 7 of 34 cases of traumatic panniculitis, 1 of 7 cases of lupus panniculitis, 1 of 20 cases of erythema induratum Bazin (nodular vasculitis), 1 of 9 cases of necrobiosis lipoidica, 1 of 4 cases of sclerotic lipogranuloma, 1 of 9 cases of infectious panniculitis (erysipelas), 1 of 2 cases of pancreatic panniculitis, and 1 of 4 cases of subcutaneous sarcoidosis. Pseudomembranous fat necrosis labelled strongly for the histiocytic markers CD68 and lysozyme. CONCLUSIONS: Our series provides data suggesting that pseudomembranous fat necrosis represents a dynamic process that varies according to the evolution of the lesion at the time of the biopsy. In biopsies taken from early foci of panniculitides pseudomembranes show vescicular or picnotic nuclei. Later, pseudomembranes retain their crenulated appearance but lack nuclear elements. Furthermore, we present histopathologic, histochemical, and immunohistochemical evidence that pseudomembranous fat necrosis results from the interaction of residual products of disintegrated fat cells and macrophages. Histiocytic markers such as CD68 and lysozyme may be used as reliable tools in order to detect pseudomembranes in panniculitides.
BACKGROUND/AIMS: The vast number of existing dedicated techniques proves that skin blood flow estimation is an unsolved problem. Specificities of cutaneous vascularization (very low blood velocity, noisy environment, complexity of the vascularization architecture) result in the unsuitability of conventional ultrasonic Doppler techniques (long acquisition time, low spatial resolution). The object here was to present a high-frequency time-domain correlation METHOD: In particular, the difficulties of adaptating this type of measurement (data processing, hardware problem) are pointed out. METHODS: Radio-frequency (RF) backscattered signals, obtained with a modified version of a home-made 20 MHz skin imaging system, are studied. Time shifts between successive windowed sections of the RF signals are determined by the mean of the cross-correlation algorithm. A realignment procedure (to remove the artefacts caused by the movements of the patient and the manipulator) and a stationary echo cancelling procedure (to remove the signals coming from the cutaneous tissues and to permit the detection of very small vessels) are used. RESULTS: In vitro results show that velocity measurements as low as 0.1 mm/s are attainable with a 80 &mgr;m axial resolution, and blood vessels of 100 &mgr;m are detectable. Our technique has also been validated by means of in vivo experiment on an erysipelas located on a human leg. In this way, a 180-&mgr;m-diameter blood vessel has been detected on a M-mode RF image and the corresponding velocity profile has been obtained. CONCLUSION: Further improvements can be expected, and the level of performance obtained in vitro in this work should be also attainable in vivo and should then provide an effective tool for skin physiology and pathology.
Familial Mediterranean fever (FMF) is an autosomal recessive disorder, characterised by short, recurrent attacks of fever with abdominal, chest or joint pain and erysipelas-like erythema. It is an ethnically restricted genetic disease, found commonly among Mediterranean populations, as well as Armenians, Turks, Arabs and Jews. Traditionally, Italians have been considered little affected by FMF, despite the geographical position of Italy (northern Mediterranean basin) and the migratory changes in its population. The objective was to characterise the demographic, clinical and genetic features of FMF in Italy. Patients of Italian origin were recruited from those referred to Italian-French medical centres for FUO (Fever of Unknown Origin) or 'surgical' emergencies; clinical history, genealogy and physical examination were recorded; all other possible infectious, neoplastic, auto-immune and metabolic diseases were excluded. Mutational analysis of the gene responsible for FMF (MEFV on 16p13.3) was performed, after which geno-phenotypical correlations were established. Italian FMF patients, 40 women and 31 men, aged from 3 to 75 years, have shown all the clinical manifestations indicative of FMF described in the literature, but with a lower incidence of amyloidosis. The genetic tests have been contributive in 42% of cases. The frequency of each different mutation has been similar to that found in a series of 'endemic' countries. The geno-phenotypical correlations have suggested the existence of genetic and/or environmental modifier-factors. Among Italians FMF seems to be more frequent than was believed in the past. The data presented are consistent with their geographical location and their history.
The skin is a milieu for controlled bacterial growth. Skin supports the growth of commensal bacteria, which protect the host from pathogenic bacteria. Environmental and local factors, host immunity, and organism adherence and virulence are intricately related to cutaneous infection. Resident gram-positive bacteria include Staphylococcus, Micrococcus, and Corynebacterium sp. Staphylococcus aureus and Streptococcus pyogenes are notoriously pathogenic in the skin. In order for bacteria to be pathogenic, they must be able to adhere to, grow on, and invade the host. Bacteria possess numerous virulence genes that allow for growth in these privileged niches. Epidermal infections caused by S. aureus and S. pyogenes include impetigo and ecthyma. Dermal infections consist of erysipelas, cellulitis, and necrotizing fasciitis. The pilosebaceous unit is involved in folliculitis, furunculosis, and carbunculosis. Moreover, S. aureus and S. pyogenes produce toxins that may elicit a superantigen response, causing massive release of cytokines. Staphylococcal scalded skin syndrome, toxic shock syndrome, and scarlet fever are all superantigen-mediated. Gram-negative organisms such as Pseudomonas aeruginosa, Pasteurella multocida, Capnocytophaga canimorsus, Bartonella sp., Klebsiella rhinoscleromatis, and Vibrio vulnificus are not typical resident skin microflora but may cause cutaneous infection.
BACKGROUND: Vibrio vulnificus infection causes rapidly progressive skin lesions and sepsis in compromised hosts with liver cirrhosis, and is often fatal. Early diagnosis and rapid treatment are important. OBJECTIVES: To clarify the characteristics of V. vulnificus infection that distinguish it from other cutaneous and soft-tissue bacterial infections and to confirm that serum creatine phosphokinase (CPK) levels are useful in early diagnosis, and are a prognostic factor for, V. vulnificus infection. METHODS: We analysed the clinical and laboratory findings (especially serum CPK levels) in eight patients with V. vulnificus infection who were treated at the Saga Medical School Hospital between January 1989 and December 1999. RESULTS: All eight patients had liver dysfunction and typical skin manifestations. Six had eaten raw seafood before onset. Seven patients had initial skin manifestations in their legs or feet and eventually died, despite prompt therapy in the intensive care unit. CPK levels of six of these seven patients were already elevated at their initial presentation. Only one patient, with skin manifestations solely on his left hand, showed and maintained a normal CPK level and survived. In 23 patients with cutaneous and soft-tissue infections (10 with necrotizing fasciitis, three with erysipelas, 10 with cellulitis), only three patients with necrotizing fasciitis and streptococcal toxic shock syndrome (STSS) showed CPK elevation. CONCLUSIONS: A high level of serum CPK in cutaneous or soft-tissue bacterial infection is considered useful for an early diagnosis of V. vulnificus infection and STSS. A history of eating raw seafood, underlying liver disease and multiple lesions suggest a diagnosis of V. vulnificus infection, rather than STSS.