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Nail coloration has many causes and may reflect systemic disease. White nails (leukonychia) are common; rubronychia is rare, whereas green (chloronychia) is occasionally evident. Chloronychia, the Fox–Goldman syndrome, is caused by infection of an often damaged nail plate by Pseudomonas aeruginosa. P. aeruginosa is an opportunistic pathogen known for localized and systemic infections. It can spread cryptically in a variety of ways, whether from an infected nail to a wound either autologously or to a patient as a surgical site infection, and many represent a threat to elderly, neonatal, or immunocompromised patients who are at increased risk of disseminated pseudomonas infection. We will review the Goldman–Fox syndrome as an occupational disorder of homemakers, nurses, plumbers, and others often with wet hands. At a time when hand washing is being stressed, especially in healthcare settings, examination of nails should be emphasized too, recalling the possibility of surgical site infection even with a properly washed and gloved medical care provider. Pseudomonas may be a community-acquired infection or a hospital or medical care setting-acquired one, a difference with therapeutic implications. Since healthcare workers represent a threat of nosocomial infections, possible guidelines are suggested.

Levamisole exposure in cocaine users is a well-recognized cause of retiform purpura, a distinctive net-like maculopapular patch. Prolonged exposure to levamisole can lead to a serious systemic syndrome known as levamisole-induced vasculitis, most commonly involving the kidneys and lungs. More recently, retiform purpura has been observed in patients with the novel coronavirus disease of 2019 (COVID-19). Due to their overlapping dermatologic and systemic manifestations, levamisole-induced and COVID-19-induced retiform purpura may mimic one another in clinical presentation. The possibility that patients may present with one or both syndromes creates a diagnostic challenge. This review of levamisole-induced and COVID-19-induced retiform purpura highlights their corresponding and distinctive features. Additionally, we propose a unique staging system for levamisole-induced retiform purpura that may be valid for future classification of COVID-19-induced retiform purpura.

Cutaneous involvement can be an important sign of both COVID‐19 and rickettsioses. Rickettsial infections may be first evident as an exanthem with eschars as a key finding. In contrast, eschars and necrotic lesions can be seen in critically ill COVID‐19 patients. Both illnesses share a similar mechanism of infecting endothelial cells resulting in vasculopathy. Rickettsia parkeri and Rickettsia 364D are both characterized by eschars unlike Rickettsia rickettsii. Other eschar causing rickettsioses such as Rickettsia conorii, Rickettsia africae, and Orientia tsutsugamushi are commonly diagnosed in people from or having traveled through endemic areas. While there is no consensus on treatment for COVID‐19, rickettsioses are treatable. Due to possibly serious consequences of delayed treatment, doxycycline should be administered given an eschar‐presenting patient's travel history and sufficient suspicion of vector exposure. The proliferation of COVID‐19 cases has rendered it critical to differentiate between the two, both of which may have overlapping vasculopathic cutaneous findings. We review these diseases, emphasizing the importance of cutaneous involvement, while also discussing possible therapeutic interventions.

Jarisch-Herxheimer reaction (JHR) should be anticipated in treating neurosyphilis with coexistent human immunodeficiency virus (HIV) encephalitis. In that context we have devised a staging classification for JHR. In addition, an illustrative case is provided to emphasize the need to consider the diagnosis of neurosyphilis in HIV patients, and if delineated, to be prepared for a severe JHR.

Empyema necessitans is a relatively rare clinical entity in which the empyema extends through the parietal pleura into the adjacent soft tissue and musculature of the chest wall. It usually occurs due to inadequate treatment of a primary lung infection. Aggregatibacter (formerly Actinobacillus) actinomycetemcomitans is a facultative anaerobic gram-negative coccobacillus that is part of the normal oral flora. Infections due to this organism usually result from aspiration in conjunction with dental disease or trauma to the oral mucosa resulting in pneumonia or empyema. It often coinfects with Actinomyces and is known to cause empyema necessitans. Cases of monomicrobial empyema necessitans due to Aggregatibacter actinomycetemcomitans in adults have rarely been reported with four such publications found on review of the literature. We present a patient with severe periodontitis who developed empyema necessitans due to Aggregatibacter actinomycetemcomitans likely from aspiration complicated by pyomyositis of the right triceps brachii and a left posterior thigh abscess.

In view of the new viral COVID-19 pandemic, the fungal Candida auris epidemic still in progress worldwide highlights non-Candida albicans candidal infections. We describe an immunocompetent woman with a cutaneous manifestation of Candida parasilopsis fungemia, a prominent eschar, which proved to be the nidus for the candidemia. We stress the value of selectively removing eschars. C. parasilopsis and C. auris are increasingly important causes of sepsis and wound infections. We emphasize that commercially available biochemical-based tests may misidentify C. auris as C. parapsilosis, and stress the added danger of C. auris to critically ill-hospitalized COVID-19 patients. Any health care facility with evidence of infection or colonization with C. auris requires very close monitoring, since this fungus is a nosocomial threat comparable to SARS-CoV-2 in its mortality and fomite adhesiveness! Both organisms have the potential to be transmitted as nosocomial pathogens; health care workers need to follow strict CDC guidelines. During this COVID-19 pandemic, every health care facility should closely monitor for the possible deadly combination of the SARS-CoV-2 and C. auris. The identification of C. auris necessitates use of sophisticated technology not readily available to make this essential diagnosis since C. auris is multi-drug resistant and isolation precautions would become paramount.

Ludwig’s angina is a rapidly spreading infection of the floor of the mouth and neck. A rare and dreaded complication of Ludwig’s angina is extension of the infection to the mediastinum. We describe a unique case of Ludwig’s angina presenting with descending necrotizing mediastinitis, with the subsequent development of Candida albicans and Candida krusei mediastinitis.

18-Fluorine fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) has been shown to have use in the diagnosis of inflammatory and infectious diseases in addition to its primary use in cancer. We describe a case of early neurosyphilis that initially presented as symmetric, generalized lymphadenopathy on PET/CT. We conclude that PET/CT may play a role in evaluating targeted diagnostic interventions, disease extent, and treatment efficacy for disseminated syphilis.

Overall (N = 254) Medicine (Floors) (n = 96) Surgery (Floors) (n = 42) Medical ICU (n = 51) Surgical ICU (n = 31) Orders adherent to policy, n (%) 84 (33.1) 31 (32.3) 18 (42.9) 13 (25.5) 16 (51.6) Time from order entry to order verification, median minutes (range) All orders 11 (0 – 2142) 13 (1 – 2142) 9 (2 – 540) 13 (1 – 919) 31 (1 – 1769) Adherent orders 7 (1 – 213) 5 (1 – 148) 8.5 (2 – 52) 4 (1 – 74) 6.5 (1 – 213) Non-adherent orders 16 (0 – 2142) 22 (1 – 2142) 13 (2 – 540) 19 (1 – 919) 416 (5 – 1769) ID approval not obtained prior to order entry, n (%) 134 (52.8) 58 (60.4) 16 (38.1) 20 (39.2) 13 (41.9)

Crohn's disease is a chronic, relapsing, inflammatory disorder which may involve any segment of the bowel from mouth to anus. The mucocutaneous manifestations of Crohn's disease in the orofacial region are multiple, including oral Crohn's disease, metastatic Crohn's disease in sites noncontiguous with the bowel system, and reactive disorders such as pyoderma gangrenosum. Clinicians should be familiar with these extraintestinal manifestations and include this important and often serious disease in the evaluation of patients with selected orofacial disorders. The recognition of these manifestations may help prevent misdiagnosis and unnecessary treatment, and facilitates timely diagnosis, palliation and definitive therapy.

Septicemia due to Pseudomonas putrefaciens was found in an elderly man with chronic leg ulcers. This organism is rarely cultured from human material and has been reported to cause skin and ear infections in only a few patients. Its potential for invasiveness is documented in this case for the fourth time.

Specimens from 300 patients were studied using five to nine aerobic and anaerobic culture media, including five that were hypertonic, Groups studied included fever of unknown origin, suspected endocarditis, endocarditis during therapy, bacteremia during therapy, abscess and cellulitis, presumed infectious arthritis, renal transplantation during rejection, collagen disease, sarcoidosis, lymphoma, and colitis. Isolates in hypertonic media were reverted to parent form by agar passage. In only 5% of these selected cases were organisms found in hypertonic, but not conventional, media that appeared on the basis of repeated isolation and/or serological studies to come from the patient. Nine of the 16 appeared to be of major significance. The two groups in which use of highly enriched, hypertonic media seemed most helpful were suspected endocarditis and undefined meningitis with negative cultures using standard media. The most effective of the hypertonic media used was 0.3 M sucrose in brain heart infusion with 20% horse serum. In most instances, the organism grew only in the hypertonic sucrose, and in most cases it appeared in conventional rather than aberrant form. Hypertonic media, especially 0.3 M sucrose, are of substantial helpin a small number of carefully selected cases.