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Bacterial conjunctivitis is a leading cause of infectious conjunctivitis in children and second most common cause in adults. Although often self-limiting, it can lead to complications like corneal scarring and systemic infections in high-risk groups including newborns and immunocompromised patients. Thus, prompt diagnosis and treatment are essential for these vulnerable populations. Common bacterial causes are Staphylococcus aureus and Streptococcus pneumoniae in adults and Haemophilus influenzae and Moraxella catarrhalis in children. Clinical features alone do not reliably identify the causative pathogen. Microbiological testing is necessary for persistent or severe cases. Topical antibiotics like azithromycin or fluorochinolones are usually prescribed. However, gonococcal and chlamydial conjunctivitis warrant systemic antibiotics due to their potential for severe complications. Increasing antibiotic resistance might even necessitate tailored therapy based on antibiotic susceptibility profiles. Screening and treating pregnant women is an effective prevention strategy by reducing perinatal transmission (especially of gonococcal and chlamydial infections). In summary, while often self-limiting, potential complications and rising antibiotic resistance underscore the importance of timely diagnosis and treatment of bacterial conjunctivitis. Preventive measures including maternal screening are crucial public health initiatives to curb the risks associated with this common eye infection., Competing Interests: Erklärung zu finanziellen Interessen Forschungsförderung erhalten: nein; Honorar/geldwerten Vorteil für Referententätigkeit erhalten: nein; Bezahlter Berater/interner Schulungsreferent/Gehaltsempfänger: nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an im Bereich der Medizin aktiven Firma: nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an zu Sponsoren dieser Fortbildung bzw. durch die Fortbildung in ihren Geschäftsinteressen berührten Firma: nein. Erklärung zu nichtfinanziellen Interessen Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

We report the case of a healthy young man who presented to our clinic with itchy skin lesions in the area of a tattoo on the back of the left hand. Bioptic and cultural confirmation of the pathogens led to the diagnosis of Mycobacterium chelonae infection. We initiated antibiotic therapy using azithromycin and linezolid with good response. Our case underlines that besides allergic skin reactions, infections as a complication after tattooing should also be included in the differential diagnosis., (© 2023. The Author(s).)

Ocular rosacea in children is a rare but often underdiagnosed condition. It is typically associated with chronic blepharoconjunctivitis, chalazia, corneal opacity and corneal neovascularization. The recommended treatment consists of topical (eyelid hygiene, steroids, cyclosporin, lubricants) and systemic (antibiotics e.g. erythromycin) measures. This case series of 8 children demonstrates the efficacy of local 1.5% azithromycin treatment together with eyelid hygiene in pediatric ocular rosacea. A further advantage of this topical treatment is that the required application of only twice daily for 3 days followed by 7 days without treatment is convenient and improves adherence to treatment.

CME Dermatology 16/Answer: Fever, Pustules and Joint Pain as Vacation Mementoes.

History and Admission Findings: A 64-year-old man complained of pain and a symmetric swelling of the clavicles. There were no fever and chills. 27 years earlier, a resection of the mandible was necessary, due to osteomyelitis. In the past, he complained of recurrent episodes of pain in the sternum and in the thoracic spine. Skin disorders were not reported., Investigations: The leucocyte count was within the normal range, however, levels of c-reactive protein and the erythrocyte sedimentation rate were increased. Autoantibodies and blood cultures were negative. On X-ray, osteosclerotic and cystic lesions in both clavicles were found, consistent with osteomyelitis. A bone scintigraphy revealed increased radionuclide activity in the clavicles and the sternum. A bone biopsy sample from the clavicle revealed signs of osteitis with fibrosis together with CD 68 und CD 138 positive cells. These findings indicated the diagnosis of a SAPHO syndrome (Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis) without skin disease., Treatment and Course: NSAIDs, bisphosphonates and azithromycin were administered , thereby sufficient pain relief was rapidly achieved., Conclusion: SAPHO syndrome is a rare disease complex including osteoarticular disorders which are frequently accompanied by skin disease. However, the diagnosis may be difficult due to a variable clinical manifestation and especially - like in our case - if skin disease is absent. Current treatment options are not evidence-based due to the rarity of the syndrome but include NSAIDs, bisphosphonates and glucocorticoids., (© Georg Thieme Verlag KG Stuttgart · New York.)

Vasoproliferative retinal tumors are benign tumors of unknown origin often accompanied by vitreoretinal inflammation. A 21-year-old female patient presented with acute reduced unilateral visual acuity. A solid yellow vascularized lesion was present in the inferior temporal retina accompanied by localized retinal detachment and accumulation of hard exudations. The only finding was an increased Bartonella henselae titer. Persistence of uveitis and blurred vision led to therapy for Bartonella henselae with macrolide antibiotics and successful tumor regression was achieved by cryotherapy.

Background: Babesiosis is a tick-borne zoonosis. Human cases of babesiosis occur worldwide but have been mainly described in North America and rarely in Europe. The disease manifestations show a broad clinical spectrum including a malaria-like syndrome. Fulminant and life-threatening infections have been described in the setting of asplenia and/or immunosuppression., Case Report: A 63-year-old splenectomized patient had been treated with rituximab because of B cell lymphoma. 4 weeks later, he developed signs of infection, anemia, subicterus, and dark urine. Laboratory investigation revealed hemolytic anemia, hemoglobinuria, and renal insufficiency. Blood smears showed Plasmodium-like intraerythrocytic parasites. He had not been exposed to malaria. He had taken frequent walks in the woods around Lake Constance in the south of Germany, where tick-borne diseases are endemic. Babesiosis was confirmed by polymerase chain reaction (PCR) and the parasite was identified as EU1. Serology was negative. Therapy with clindamycin and quinine induced remission. Following a relapse, retreatment with atovaquone and azithromycin was initiated. After several months, seroconversion occurred and the patient cleared the parasite 8 months after first admission., Conclusion: Human babesiosis does occur in Germany. Patients with splenectomy and/or immunosuppression and malaria-like symptoms should be evaluated for babesiosis by blood smear and PCR.

Legionella species are ubiquitous in aquatic environments. About 50 years ago they entered the engineered (technical) environment, i.e. warm water systems with zones of stagnation. Since that time they represent a hygienic problem. After transmission to humans via aerosols legionellae might cause Legionella pneumonia (legionnaires' disease) or influenza-like respiratory infections (Pontiac fever). Epidemiological data suggest that Legionella strains might differ substantially in their virulence properties. Although the molecular basis is not understood L. pneumophila serogroup 1 especially MAb 3/1-positive strains cause the majority of infections. The main virulence feature is the ability to multiply intracellularly. After uptake into macrophages legionellae multiply in a specialized vacuole and finally lyse their host cells. Several bacterial factors like surface components, secretion systems and iron uptake systems are involved in this process. Since the clinical picture of Legionella pneumonia does not allow differentiation from pneumoniae caused by other pathogens, microbiological diagnostic methods are needed to establish the diagnosis. Cultivation of legionellae from clinical specimens, detection of antigens and DNA in patients' samples and detection of antibodies in serum samples are suitable methods. However, none of the diagnostic tests presently available offers the desired quality with respect to sensitivity and specificity. Therefore, the standard technique is to use several diagnostic tests in parallel. Advantages and disadvantages of the diagnostic procedures are discussed. Therapeutic options for Legionella infections are newer macrolides like azithromycin and chinolones (ciprofloxacin, levofloxacin and moxifloxacin).

M. malmoense could be cultivated in sputum samples of a 49-year-old patient with destructive pulmonary disease. The conventional antituberculous therapy (started because initially a presumptive diagnosis of tuberculosis was established) was altered to ethambutol, rifabutin, clarithromycin and ciprofloxacin, followed by a long-time therapy with azithromycin or clarithromycin. But till now it was not possible to eradicate the mycobacteria from the respiratory tract (insufficient compliance, interruptions of the therapy due to side effects, excessive smoking). Infections due to M. malmoense are rare events. Many patients have disposing underlying diseases. In most cases it is a pulmonary infection. The most frequent used antibiotics are rifampicin (or rifabutin), ethambutol and clarithromycin.

Objective: Lymphadenitis colli due to NTM should always be considered in children with cervical Lymphadenitis. For Germany there is a lack of data concerning the incidence, the epidemiology, the diversity and frequency of the different bacteria, the diagnosis, the clinical manifestation and the medical treatment., Methods: By means of a questionnaire, which was retrospective for 1985 to 1994 and was sent to 277 children's hospitals in Germany, we collected data on Lymphadenitis colli in Germany. In our study we also incorporated cases from the "National Laboratory for Mycobacteria" in Borstel as well as six cases from our hospital in Mainz. Therefore our data includes both clinical (28) and laboratory (30) cases. Additionally we screened the literature on "Lymphadenitis colli in children due to NTM"., Results: A total of 51 cases of Lymphadenitis due to NTM could be identified. The illness occurs typically in young children up to six years of age. The most frequent cause were species of the Mycobacterium avium-intracellulare-scrofulaceum complex. Except for the local diagnosis of a cervical Lymphadenitis other clinical symptoms are missing, just as specific laboratory parameters with a subacute or chronic course. The tuberculin skin test can be false positive. The diagnosis is confirmed by biopsy and histology as well as through microbiological tests., Conclusions: The best treatment is complete surgical excision, whereas the importance of additional or exclusive treatment with Clarithromycin, Rifabutin and other antibiotics could not be clarified completely. But in patients with AIDS Rifabutin and other drugs could perhaps be useful, even for prophylaxis. Also if complete excision is impossible, treatment with certain drugs (Clarithromycin or Azithromycin in combination with Rifampicin) will be recommended. It still remains in question if NTM infections in children are really increasing.

Confluent and reticulated papillomatosis is a fairly rare dermatosis of still unknown origin affecting mostly female young adults. The lesions are mainly localized in the midline of the trunk. Systemic treatment is the treatment of choice because the disease is resistant to topical therapy and recurrences are often seen. In recent publications retinoids and minocycline have been reported as the favourite therapeutic approaches. We successfully treated a 19-year-old-girl with azithromycin resulting in a complete healing of all skin lesions. The patient has been free of disease for five months. Based on our own case and data in literature, azithromycin is an effective, reasonable and safe therapeutic alternative.

Juvenile and adolescent "Chronic Recurrent Multifocal Osteomyelitis" (CRMO) is described on the basis of literature and analysis of 43 own cases (23 cases in children or adolescents). This systemic, non-purulent inflammatory disease occurs mainly metaphyseal in long bones, in pelvic bones or as spondylitis and is not as rare as it seemed. Basis of the disease is a primarily chronic, sterile, in phase of onset often monotopic (e.g. clavicle) and later frequently polytopic osteomyelitis, possibly triggered by an immuno-pathological process (e.g. Proprionibacterium acnes), and showing histologically plasmacellular invasion and a sclerosing process in different stages. Association with pustulous dermatosis (psoriasis, acne, palmo-plantar pustulosis) is found in about 25 % of children and adolescents and in more than 50 % of the adult patients. 5 differents types of distribution of osteomyelitic lesions can be found by using Te99m-bone scan primarily, of which the "pelvic type" is the most common. Because of the close neighbourhood of meta-/epiphyseal osteomyelitic focuses, "sympathetic arthritis" with synovitis is seen frequently. A therapeutic approach with azithromycine and calcitonine is presented.

We report about the juvenile and adolescent pelvic type of CRMO in 7 girls and 4 boys. The results show from solitary up to 7 pelvic lesions (average 3 lesions) predominantly in the acetabular and paraacetabular region (sometimes with hip joint effusion as a sign for concomitant coxitis).Tc99m-bone-scan is helpful to evaluate exactly the pattern of bone affection. We find 3 stages of an primarily chronic, non-purulent osteomyelitis going along with a "plasma-cell-sclerotic process", leading to a Garrè-type sclerosing end-stage, which probably heals after some years spontaneously, projecting on clinical symptoms and radiological appearance. The concomitant coxitis ("sympathetic coxitis") is clinically often in the foreground, but reversible. Pain in case of CRMO responds surprisingly well on medication with acithromycine. Knowing about CRMO in its different clinical appearances - especially concerning what we call "sympathetic coxitis" - can be a useful for pediatric rheumatologists and orthopedic surgeons, as well as MRI-focused radiologists and pathologists. Therapy might find a useful drug in acithromycine. In conclusion we d like to point out, that CRMO is one entity under the "roof" of the so called SAPHO-syndrome, which again shows us, that SAPHO-syndrome ist not a diagnosis itself but more a sign-post on the way to a correct diagnosis.

History and Clinical Findings: A 39-year-old HIV positive patient developed myalgia, headache and cough 4 weeks after a tick bite. His temperature was 37.4 degrees C and a circular pale erythema was noted over the left lower leg., Investigations: C-reactive protein was raised to 120 mg/l, white blood cell count was 5860/microliter, CD4-lymphocyte count 250/microliter. The chest radiogram showed pneumonitic infiltration in the left lower lobe. There were IgM antibodies against Borrelia burgdorferi., Treatment and Course: Left lower lobe pneumonia and chronic erythema migrans were diagnosed and he was given oral azithromycin (500 mg on the first day and 250 mg for 4 days). The pneumonia cleared up, but 2 weeks later he developed symptoms of meningitis (496 cells per microliter, 87% lymphocytes, positive Borrelia burgdorferi antibody titer), which quickly and lastingly responded to ceftriaxon (2 g daily by brief infusion for 14 days)., Conclusion: This immune-compromised HIV-infected patient developed disseminated borreliosis with CNS involvement 2 weeks after the occurrence of chronic erythema migrans. The initial treatment of the latter with azithromycin was unable to prevent the meningitis. It is unlikely that there was a causal connection between the borreliosis and the pneumonia.

We report the case of a 25-year-old female patient with severe aggravation of myasthenia gravis due to azithromycin which was prescribed for an influenza syndrome. One hour after the intake of 500 mg azithromycin the patient developed weakness of the legs and respiratory distress due to respiratory muscle failure. She was hospitalized in a comatose state and required intubation and mechanical ventilation for six days. Acute worsening of myasthenia gravis was observed in this patient in 1986 after parenteral administration of erythromycin. Erythromycin causing aggravation of myasthenia gravis by interfering with neuromuscular transmission is reported in the literature. The close temporal relationship between the intake of azithromycin and severe worsening of myasthenia gravis in our patient suggests that azithromycin, a new azalid-antibiotic of the macrolid group, can exacerbate myasthenia gravis. We conclude that azithromycin should be added to the list of drugs to be used with caution in patients with myasthenia gravis.