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The present study was designed to investigate the effect of FPZ, a total flavonoids ointment topical application from Pouzolzia zeylanica var. microphylla (Wedd.) Masam, Urticaceae, on skin infections in mice. FPZ ointment anti-infective effect was investigated on Staphylococcus aureus-induced skin abscess and skin ulcers in mice by evaluating the variation in abscess volume, histopathology of skin tissue and healing rate. Secondary, it is topical anti-inflammatory activities on carrageenan-induced hind paw edema in mice was estimated. Besides, FPZ ointment fingerprint was performed by using ultra-performance liquid chromatography and FPZ ointment chemical constituents were isolated and identified by repeated column chromatograph and spectroscopic methods. The results revealed that FPZ ointment topical application at the concentration of 2.5–10% could attenuate skin abscess and ulcers and accelerate wound healing, as compared with control group treated with vehicle (p

Loss-of-function (LOF) mutations in signal transducer and activator of transcription 3 (STAT3) gene causes autosomal dominant hyper immunoglobulin E syndrome (AD-HIES or Job’s Syndrome), a rare and complex primary immunodeficiency (PID) syndrome characterized by increased levels of IgE (>2000 IU/mL), eosinophilia, recurrent staphylococcal skin abscesses, eczema, recurrent pneumonia, skeletal and connective tissue abnormalities. Although bacterial and fungal infections are common in AD-HIES, susceptibility to parasitic infections has not been reported. Alveolar echinococcosis (AE), a zoonosis caused by the growth of the Echinococcus multilocularis (EM) metacestode, mimics slow-growing liver cancer. The mortality rate of AE is very high when it is diagnosed late or under-treated. Here, we report a 14-year-old boy with AE infections of the liver and the lung resulting in liver failure and diagnosed as STAT3-LOF. To our knowledge, the association between these two conditions has not been reported in the literature before.

Aims Primary immunodeficiencies are not often documented, but the prevalence in developed countries is estimated at approximately 1 in 1200. Lack of statistics on the Sub- Saharan African population leads to inappropriate management, poor quality of life and markedly reduced survival. This presentation aims to highlight the need for timely identification and early diagnosis of primary immunodeficiencies, hence improved care and survival of affected patients. Methods A retrospective chart review of a patient who presented with a history of recurrent respiratory tract infections since the age of four months, often requiring inpatient care two to three times every year. Results The history included infantile eczema and recurrent respiratory infections for which the patient had been on follow up at the pediatric pulmonology clinic. She also had global developmental delay and was being followed up at the pediatric neurology clinic. There was a history of widespread skin abscesses which resolved on treatment. At 6 years, she was non- verbal, could only walk short distances and was on home oxygen. Examination revealed a dull looking, wasted child who was pale and had sparse, brittle, silvery hair, poor dentition, global hypotonia, reduced muscle bulk, and skin depigmentation with features of longstanding eczema. Weight for age was at the 3rd centile. She was saturating at 75% in room air and a chest CT scan revealed lower lung lobe collapse with a possible diagnosis of interstitial lung disease. Abdominal examination showed hepatomegaly. There were no murmurs on auscultation, but there was severe pulmonary arterial hypertension on echocardiography. Given the frequent infections, skin depigmentation, silvery hair and global developmental delay, a diagnosis of suspected Griscelli syndrome was made. The patient passed away at the age of 6 years while on home care. Conclusion There is need for more documentation of primary immunodeficiency disorders in order to empower clinicians to easily identify cases and offer prompt treatment.

Patients with skin and soft tissue infections may appear with the abscess. Erroneous diagnosis of these entities is common, and should carefully consider the possible alternative diagnoses. Risk for developing skin abscess factors includes disruption of the skin barrier, edema, venous insufficiency, and immune suppression. However, healthy individuals who have no risk factors may also develop these diseases. The most common microbiologic cause of abscess, a commonly group Streptococcus or Streptococcus pyogenes; Staphylococcus aureus (including methicillin-resistant strains) is a notable but less common cause. The most common microbiologic cause of skin abscess is S. aureus; a skin abscess can be caused by more than one pathogen. The diagnosis is based on skin abscess usually on the clinical manifestations. It must be subject to patients with disposable abscess incision and drainage, with a test of culture and susceptibility of materials wet. There is no justification for the blood of patients in the cultures of the abovementioned circumstances. It can be a useful radiographic examination to determine whether the skin abscess is present (via ultrasound) to distinguish cellulitis from osteomyelitis (via magnetic resonance imaging). There may be a justification for radiological assessment in patients with immune suppression, diabetes, venous insufficiency, or lymphedema in patients with persistent symptoms of systemic lymphatic obstruction.

The primary malignant tumor that most commonly metastasizes to the skin in women is breast cancer and manifest variety forms of clinical presentation. Breast cancer has the ability to metastasize to any site such as the ovaries, lung, liver, bone, brain, gastrointestinal tract and skin. The skin is not a common site for metastatic spread. We would like to report a case of a 56 years old female patient with an infectious mass in her left inframammary fold with discharge. The patients had a one-year history of left breast pruritus and with a mass which increased in size over two months. There was axillary lymphadenopathy, tenderness, and erythema of breast skin around the mass in the physical examination and just elevated erythrocyte sedimentation rate in laboratory tests. The patient did not benefit from antimicrobial therapy. The histological examination revealed a tumor with sheets of malignant cells and many necrotic areas. The diagnosis was invasive ductal breast carcinoma, cutaneous metastases, and lymphatic embolization.

Author(s): Russell, Frances M.; Rutz, Matt; Rood, L. Ken; McGee, Justin; Sarmiento, Elisa J. | Abstract: Introduction: Skin and soft tissue infections (SSTI) occur along a continuum from cellulitis to abscess. Point-of-care ultrasound (POCUS) is effective in differentiating between these two diagnoses and guiding acute management decisions. Smaller and more superficial abscesses may not require a drainage procedure for cure. The goal of this study was to evaluate the optimal abscess size and depth cut-off for determining when a drainage procedure is necessary.Methods: We conducted a retrospective study of adult patients with a SSTI who had POCUS performed. Patients were identified through an ultrasound database. We reviewed examinations for the presence, size, and depth of abscess. Medical records were reviewed to determine acute ED management and assess outcomes. The primary outcome evaluated the optimal abscess size and depth when a patient could be safely discharged without a drainage procedure. We defined a treatment failure as a return visit within seven days requiring admission, change in antibiotics, or drainage procedure.Results: A total of 162 patients had an abscess confirmed on POCUS and were discharged from the ED without a drainage procedure. The optimal cut-off to predict treatment failure by receiver operating curve analysis was 1.3 centimeters (cm) in longest dimension with a sensitivity of 85% and specificity of 37% (area under the curve [AUC] 0.60, 95% confidence interval [CI], 0.44-0.76), and 0.4cm in depth with a sensitivity of 85% and specificity of 68% (AUC 0.83, 95% CI, 0.74-93).Conclusion: This retrospective data suggests that abscesses greater than 0.4 cm in depth from the skin surface may require a drainage procedure. Those less than 0.4 cm in depth may not require a drainage procedure and may be safely treated with antibiotics alone. Further prospective data is needed to validate these findings and to assess for an optimal size cut-off when a patient with a skin abscess may be discharged without a drainage procedure.

A 12-year-old female was evaluated in the emergency department (ED) for a swelling on her right leg. She is previously healthy; however, she has several mosquito bites on her leg which she has been scratching. Over the past 12 hours, she has had worsening redness and swelling around one of the mosquito bites, with associated fevers and vomiting. In the ED, she is febrile to 39 °C. Her physical examination is significant for a 10-cm tender area of redness, induration, warmth, and fluctuance on her right leg just above her knee. Incision and drainage of the abscess are performed at the bedside. The evacuated purulent material is sent for Gram stain and bacterial culture. She is admitted to the hospital and treated with intravenous vancomycin and cefazolin to target the most likely causes of the infection: Streptococcus pyogenes and methicillin-susceptible and methicillin-resistant Staphylococcus aureus. Culture results reveal Staphylococcus aureus, a catalase-positive, coagulase-positive gram-positive coccus typically seen as purple grape-like clusters on Gram stain. Rapid latex agglutination testing is positive for the detection of penicillin-binding protein (PBP) 2A. Expression of this protein further identifies the organism as methicillin-resistant S. aureus (MRSA). IV cefazolin was discontinued. Vancomycin is continued while awaiting the full antimicrobial susceptibility report. On hospital day 2, antimicrobial susceptibilities reveal that the isolate is susceptible to clindamycin. At this time, the patient is afebrile, showing signs of clinical improvement, and tolerating oral intake without vomiting. Her treatment is switched from IV vancomycin to oral clindamycin, and she is discharged home with a diagnosis of MRSA skin abscess. Her infection resolves completely after treatment with a 10-day course of clindamycin.

Staphylococcus aureus (methicillin resistant or methicillin sensitive) can cause a wide variety of skin infections, ranging from a mild cellulitis to necrotizing fasciitis. Since the emergence of community-associated MRSA (CA-MRSA) in the 1990s, skin abscesses remain one of the most common cutaneous infections encountered in both the outpatient and inpatient settings.

We surveyed 323 members of the Pediatric Infectious Diseases Society about their clinical practices for skin abscess management based on the 2011 Infectious Diseases Society of America guidelines and contemporary evidence. Despite this guideline and recent randomized trials, variability exists among pediatric infectious diseases clinicians in current skin and soft tissue infection management practices.

Background Superficial skin abscesses are commonly encountered in emergency medicine practice. Standard treatment includes incision, drainage, and often packing with a gauze strip. The packing component of the procedure has several negative potential outcomes, is painful, and necessitates a return visit for removal. Discussion Here we report the first case in which a novel silicon packing device was utilized. The patient presented with a facial abscess, which was incised and drained. The novel device was inserted, and removed by the patient independently, without complication. Both patient and provider reported satisfaction with the novel procedure, and noted low pain scores. Conclusions This device has the potential to replace traditional packing, and will require further study through a controlled trial to assess for safety and efficacy.

Mycoplasma pneumoniae is a common atypical respiratory pathogen causing community-acquired pneumonia in children. Co-infection with other respiratory viruses is common in pediatric patients but super-infection with bacteria other than Streptococcus pneumoniae and Haemophilus influenzae is rare. The first case of Chromobacterium violaceum infection incubated during and manifested after pneumonia caused by Mycoplasma pneumoniae in a 12-month old girl without any known history of immunodeficiency is here reported. The patient developed fever with redness and swelling over the middle phalanx of the right hand index finger which progressed to the formation of skin abscess. Following a course of intravenous meropenem and surgical drainage of the skin abscess, the patient fully recovered and was discharged.

Non-purulent lower extremity cellulitis (NLEC) is a common clinical diagnosis with beta-hemolytic streptococci and Staphylococcus aureus considered as the most frequent causes. In 1999, the United States Public Health Service alerted clinicians of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections in four children in the Upper Midwest. Since then, it has become a well-recognized cause of skin and soft tissue infections, in particular, skin abscess. A previous population-based study of NLEC in Olmsted County, Minnesota reported an unadjusted incidence rate of 199 per 100,000 person-years in 1999, but it is unknown whether CA-MRSA subsequently has impacted NLEC incidence. We therefore sought to determine the population-based incidence of NLEC since the emergence of CA-MRSA. Age- and sex-adjusted incidence (per 100,000 persons) of NLEC was 176.6 (95% CI: 151.5, 201.7). Incidence differed significantly between sexes with age-adjusted sex-specific rates of 133.3 (95% CI: 104.1, 162.5) and 225.8 (95% CI: 183.5, 268.0) in females and males, respectively. Seasonal incidence differed, with rates of 224.6 (95% CI: 180.9, 268.4) in warmer months (May–September) as compared to 142.3 (95% CI: 112.8, 171.9) in colder months (January–April and October–December). Despite emergence and nationwide spread of CAMRSA since 1999 in the United States, the incidence of NLEC in Olmsted County was lower in 2013 than in 1999, particularly among females. This suggests that CA-MRSA is not a significant cause of NLEC and that NLEC cases are seasonally distributed. These findings may be important in formulation of empiric therapy for NLEC and in patient education as many patients with NLEC are prone to recurrent bouts of this infection.

Objectives Soft tissue abscesses are common in the pediatric emergency department (ED). Ultrasound (US) can be used to both diagnose soft tissue abscesses as well as guide drainage. We hypothesized that clinical failure rates would be less in pediatric patients with suspected skin abscesses when evaluated with US. Methods We performed a retrospective review of suspected pediatric skin abscesses at 4 EDs over a 22-month period. Cases were identified through electronic medical record descriptions, discharge diagnoses, and US database records. Data on US use, findings, and outcomes were abstracted to an electronic database. Comparisons between groups included US versus non-US (primary outcome) as well as surgical drainage vs nonsurgical drainage (secondary outcome). Results A total of 377 patients were seen with concern for a potential skin abscess; 141 patients (37.4%) underwent US imaging during their visit, and 239 (63.4%) underwent incision and drainage (ID P

BACKGROUND: Uncomplicated skin abscesses are common, yet the appropriate management of the condition in the era of community-associated methicillin-resistant Staphylococcus aureus (MRSA) is unclear. METHODS: We conducted a multicenter, prospective, double-blind trial involving outpatient adults and children. Patients were stratified according to the presence of a surgically drainable abscess, abscess size, the number of sites of skin infection, and the presence of nonpurulent cellulitis. Participants with a skin abscess 5 cm or smaller in diameter were enrolled. After abscess incision and drainage, participants were randomly assigned to receive clindamycin, trimethoprim–sulfamethoxazole (TMP-SMX), or placebo for 10 days. The primary outcome was clinical cure 7 to 10 days after the end of treatment. RESULTS: We enrolled 786 participants: 505 (64.2%) were adults and 281 (35.8%) were children. A total of 448 (57.0%) of the participants were male. S. aureus was isolated from 527 participants (67.0%), and MRSA was isolated from 388 (49.4%). Ten days after therapy in the intention-to-treat population, the cure rate among participants in the clindamycin group was similar to that in the TMP-SMX group (221 of 266 participants [83.1%] and 215 of 263 participants [81.7%], respectively; P = 0.73), and the cure rate in each active-treatment group was higher than that in the placebo group (177 of 257 participants [68.9%], P

This article aims to look at the treatment and management of patients presenting with delayed tooth eruption of the permanent dentition. We describe the case of a 17-year-old girl who presented having been diagnosed with Hyper-IgE syndrome. The patient was positive for the STAT-3 gene and presented with a history of some classic Hyper-IgE features. There was a history of multiple skin abscesses and she was on long-term antibiotics. She presented in the mixed dentition with multiple retained deciduous teeth and a full complement of unerupted and fully formed permanent teeth. This article will describe features of this syndrome and discuss management strategies for patients presenting with delayed eruption. Clinical Relevance: This case study highlights the difficulties in managing patients who present with retained primary dentition at an older age. It also presents a rare case presentation of a patient with Hyper-IgE.

Michael Stanley Ellis,1 Joseph T Nelson,2 Jeffrey Zane Kartchner,1 Karl Andrew Yousef,1 William J Adamas-Rappaport,3 Richard Amini4 1College of Medicine, The University of Arizona, Tucson, AZ, USA; 2Department of Orthopedic Surgery, The University of Michigan, Ann Arbor, MI, USA; 3Department of Surgery, 4Department of Emergency Medicine, The University of Arizona, Tucson, AZ,USA Abstract: Ultrasound imaging is a rapid and noninvasive tool ideal for the imaging of soft tissue infections and is associated with a change of clinician management plans in 50% of cases. We developed a realistic skin abscess diagnostic and therapeutic training model using fresh frozen cadavers and common, affordable materials. Details for construction of the model and suggested variations are presented. This cadaver-based abscess model produces high-quality sonographic images with internal echogenicity similar to a true clinical abscess, and is ideal for teaching sonographic diagnostic skills in addition to the technical skills of incision and drainage or needle aspiration. Keywords: undergraduate medical education, abscess model, ultrasound, ultrasound education, ultrasound-guided needle aspiration

Background Injection-site vein loss and skin abscesses impose significant morbidity on people who inject drugs (PWID). The two common forms of street heroin available in the USA include black tar and powder heroin. Little research has investigated these different forms of heroin and their potential implications for health outcomes. Methods A multiple-choice survey was administered to a sample of 145 participants seeking services at reduction facilities in both Sacramento, CA and greater Boston, MA, USA. Multivariate regression models for reporting one or more abscesses in one year, injection-site veins lost in six months, and soft tissue injection. Results Participants in Sacramento exclusively used black tar (99%), while those in Boston used powder heroin (96%). Those who used black tar heroin lost more injection-site veins ( β =2.34, 95% CI: 0.66–4.03) and were more likely to report abscesses (AOR=7.68, 95% CI: 3.01–19.60). Soft tissue injection was also associated with abscesses (AOR=4.68, 95% CI: 1.84–11.93). Consistent venous access (AOR: 0.088, 95% CI: 0.011–0.74) and losing more injection sites (AOR: 1.22, 95% CI: 1.03–1.45) were associated with soft tissue injection. Conclusion Use of black tar heroin is associated with more frequent abscesses and more extensive vein loss. Poor venous access predisposes people who inject drugs to soft tissue injection, which may constitute a causal pathway between black tar heroin injection and abscess formation. The mechanisms by which black tar heroin contributes to vein loss and abscess formation must be further elucidated in order to develop actionable interventions for maintaining vein health and decreasing the abscess burden. Potential interventions include increased access to clean injection equipment and education, supervised injection facilities, opioid substitution therapy, and supply chain interventions targeting cutting agents.

Background Tedizolid phosphate has activity against gram-positive pathogens, including methicillin-resistant Staphylococcus aureus, and was approved for the treatment of ABSSSI in adults in 2014. This study compared the safety and efficacy of TZD with protocol-specified, active comparators for the treatment of ABSSSI in adolescents. Methods This was a randomized, assessor-blind, global, multicenter, phase 3 study of TZD vs. active comparator for the treatment of gram-positive ABSSSI in adolescents (aged 12 to < 18 years; NCT02276482). Enrolled patients were stratified by region and randomized 3:1 to TZD 200 mg (IV and/or oral) once daily for 6 days or investigator-selected active comparator per local standard of care (IV vancomycin, linezolid, clindamycin, flucloxacillin, or cefazolin, and/or oral linezolid, clindamycin, flucloxacillin, or cephalexin) for 10 days. The primary endpoint was safety. The percentages of patients with treatment-emergent adverse events (TEAEs) were documented; secondary efficacy endpoints included the blinded investigator’s assessment of clinical success at a test of cure visit (18–25 days after start of dosing) and early clinical response (≥20% reduction from baseline lesion area) at 48–72 h. No hypothesis testing was planned for the treatment groups. Results Of the 121 patients enrolled, 120 were treated (TZD, N = 91; comparator, N = 29). Median (range) age was 15 (12–17) years. Most patients were male (62.5%), white (86.7%), and enrolled in Europe (78.3%). Infections included major cutaneous abscess (42.5%), cellulitis/erysipelas (40.0%), and infected wound (17.5%). At baseline, the median (range) lesion surface area was 82.1 (14–978) cm2. Of those with gram-positive cultures (n = 64), S. aureus was most frequently isolated (n = 55 [85.9%]) with 3 isolates (4.7%) being methicillin resistant. TZD was well tolerated, and TEAEs were balanced between treatment arms (TZD, 14.3%; comparator, 10.3%). A total of 3 (3.3%) patients in the TZD group and 1 (3.4%) in the comparator group experienced a single-drug-related TEAE. Clinical success rates were high and similar between treatment groups (table). Conclusion TZD demonstrated comparable safety and efficacy to comparator in the treatment of ABSSSI in adolescents. Disclosures All authors: No reported disclosures.

Background Incision and drainage (I&D) is the most common treatment for skin abscesses. A recent randomized clinical trial (RCT) of outpatients with limited (≤5 cm) skin abscesses demonstrated antibiotic therapy with clindamycin or trimethoprim-sulfamethoxazole (TMP-SMX) was superior to I&D alone. We performed a subgroup analysis to measure the effect of antibiotic duration and abscess size on clinical cure at 7–10 days after antibiotic completion. Methods Participants with complete data regarding adherence to the 10-day treatment were included. Demographic and baseline clinical features were compared using t-test, Pearson’s chi-square or Fisher’s exact test, or a non-parametric equivalent where appropriate. Largest abscess dimension (cm) was dichotomized by median size. The effect of antibiotic duration, abscess size (≤ median vs. >median) and covariates on clinical cure were measured using logistic regression. Breslow-Day Test for Homogeneity was used to assess the interaction between treatment and abscess size. Results Of 786 participants in the intention-to-treat analysis, complete adherence data were available for 680 (87%) participants. Of these, 463 (68%) received either antibiotic: 421 (91%) completed 10 days of therapy, 29 (6.3%) ≤7 days and 20 (4.3%) ≤5 days. Only antibiotic treatment duration was associated with clinical cure (table). Odds of clinical cure were 1.7 (95% CI: 1.5, 2.0) times higher for each additional day of treatment. Median abscess size was 2.5 cm (range: 0.2–5); 364 participants had abscesses ≤ median vs. 316 >median. Assessed continuously, abscess size was not associated with cure within antibiotic groups (table) or between placebo and treatment groups (OR 0.94, 95% CI: 0.58–1.5). Stratifying on size, no significant interaction was observed with antibiotic treatment (Breslow-Day P = 0.13). Conclusion Adherence to the treatment protocol was high. These data suggest that longer courses of antibiotic therapy in conjunction with I&D are associated with successful treatment of limited skin abscesses. Size was not associated with clinical cure. Prospective RCTs to determine the optimal length of treatment are needed. Disclosures All authors: No reported disclosures.

Behcet disease (BD) is a neutrophilic dermatosis characterized by relapsing flares of orogenital aphthous ulcers, uveitis, and skin inflammation.1, 2, 3 Extracutaneous manifestations involve gastrointestinal, neurologic, pulmonary, and cardiac systems.1 The spectrum of skin manifestations includes erythema nodosum, papulopustular lesions, and pathergy. Skin abscesses, leukocytoclastic vasculitis, bullae, or lesions mimicking Sweet syndrome or pyoderma gangrenosum (PG) are rare.1, 2, 3 We describe a patient with atypical BD with endocarditis, PG-like ulcerations, and methicillin-resistant Staphylococcus aureus (MRSA)-positive abscesses, highlighting a unique constellation of infection and immune dysregulation.

Cervical necrotizing fasciitis (CNF) is a rapidly spreading deep neck infection with a high mortality rate if left untreated. The occurrence of necrotizing infections in the head and neck region is uncommon; therefore, it is a rare cause of chest pain presenting to the emergency department. Here, we present an interesting case of fungal cervical skin abscess complicated by necrotizing fasciitis that progressed to involve the mediastinum, causing necrotizing mediastinitis with pneumomediastinum in an elderly female. The patient presented to the emergency department with chest pain, shortness of breath, and fever. She had a 10-day history of a mass in the anterior midline of her neck with odynophagia. After radiologic confirmation, she was taken to the operating room where she underwent incision and drainage with debridement and washout. Postoperatively, she was given broad-spectrum antibiotics empirically, which were later replaced with intravenous (I/V) fluconazole after culture reports. Prompt diagnosis and treatment lead to the early recovery of the patient and subsequent discharge without any complications. We report this case to draw the attention of emergency medicine physicians and clinicians to this rare and life-threatening but treatable condition. Expeditious diagnosis and treatment lead to early recovery and fewer postoperative complications.

Skin and soft-tissue infections (SSTI) present regularly as cutaneous abscesses which require surgical drainage. These abscesses often affect younger patients and interfere with their independency substantially. Existing guidelines display heterogeneous recommendations concerning surgical aftercare. Primary aim of this survey was to present a nomogram for standard abscess therapy based on international expert opinions. An online survey dealing with standard of care protocols for cutaneous abscesses concerning surgical treatment and aftercare was created. The survey was conducted in 2017 during two international conferences held in Switzerland. 490 surgeons originating from 66 nations participated in this survey with the majority coming from Europe and Asia. Indication for surgery, operation type, and wound rinsing were answered homogeneously. Perioperative setting (45% sterile, 55% semi-sterile), anesthesia (45% local, 55% general), antibiotic therapy (38% always, 35% never, 27% other), irrigation fluid (54% sterile, 32% non-sterile, 14% antiseptic), irrigation frequency (55% once daily, 30% twice daily), and wound dressing (69% packing, 31% coverage) were heterogeneously answered topics. Treatment and aftercare of simple primary skin abscesses are processed heterogeneously throughout the world. Focus should be on optimal patient focused treatment with minimal socio-economic impact. Future studies should focus on the validation of the different postoperative treatment options with the aim to develop a socio-economically accepted algorithm.

Background and aims Stimulator of interferon genes (STING)-associated vasculopathy with onset in infancy (SAVI) is firstly described in 2014 as a type I interferonopathy that resulting from heterozygous mutations of TMEM173. This gene encodes the STING adaptor protein, and mutations lead to a gain of function on STING and overproduction of interferon beta. SAVI is characterized by neonatal-onset systemic inflammation, a severe cutaneous vasculopathy and interstitial lung disease. JAK inhibitors are considered as an effective therapeutic strategy. We sought to describe two missed diagnosed patients with SAVI (P1 and P2) in order to draw attention to this illness. Methods The clinical data were collected and Sanger sequencing of the gene TMEM173 was performed. An introspection of missed diagnosis and differential diagnosis was discussed. Results The two boys shared similar manifestations including recurrent skin abscess in winter with skin lesions and recurrent respiratory tract infections since their births. It occurred to us neutrophil defects like CGD but NBT test and DHR123 were normal for both of them in 2011. Peroxidase staining was positive and no mutations in MYD88 (P1). Computed tomography of the chest revealed pulmonary fibrosis yet no relevant genes (including ABCA3, SFTPC) mutations were found. Joint pain was significant for P2 but Naproxen was ineffective. Treatments with antibiotics turned out little improvement and wouldn’t prevent the progression. Finally, both of them died of respiratory and circulatory failure in 2012 and 2016 respectively. Recently, genetic mutations (c.463 G>A and c.461 A>G) in exon5 of TMEM173 were discovered, confirming the diagnosis of SAVI. Conclusions Owing to unfamiliarity with this disease, some cases would have been misdiagnosed or missed diagnosed. Thus, we propose that SAVI should be taken into consideration for children with chilblain skin lesions and pulmonary fibrosis after ruling out other related genes mutations.

A traveler presented with a furuncular skin abscess and periorbital edema. A larva was surgically removed from the abscess and identified as a larva of Cordylobia rodhaini. Myiasis caused by C. rodhaini is called Lund’s fly myiasis and only rarely is reported in humans. After disinfection, the remaining lesion healed without further intervention and the edema resolved.

BACKGROUND Superficial skin abscesses account for a significant burden of emergency surgical admissions. The aim of this study was to evaluate the effectiveness of an ambulatory care pathway for emergently treating abscesses of the body requiring operative drainage. METHOD A retrospective study of a prospective patient database was performed, using randomized patient selection. Patient demographics, length and cost of stay were compared between patients undergoing operative management for skin abscess before and after the implementation of the fast-track ambulatory abscess pathway (FAAP). RESULTS In total, 100 patients were analysed with 50 in the pre-ambulatory care pathway group and 50 in the FAAP group. The pre-ambulatory care pathway group had a mean age of 37.7 ± 15.8 years versus FAAP group of 35.3 ± 14.5 years. Total length of stay for the group was 85 versus 17 days with a mean comparison of 1.7 days versus 0.34 days (P

The standard treatment of cutaneous abscesses in the emergency department is incision and drainage (I&D). The purpose of this investigation is to determine the feasibility of using a povodine-iodine topical antiseptic solution (PVP-I) as a clinical adjunct in the treatment of superficial skin abscesses after I&D, and the data is related to "Pilot Study to Evaluate the Adjunct Use of a Povidone-Iodine Topical Antiseptic in Patients with Soft Tissue Abscesses" [Olson et al., 2019]. The data aims to determine if the daily application of PVP-I in the wound cavity and as an antiseptic hand wash would confer any benefit over I&D alone. The primary outcome was clinical cure 7-10 days after I&D. The secondary outcomes were rate of new abscess development and spread of infection in household contacts (HC) within 30 days.

Hidradenitis suppurativa is a chronic skin disease characterised by repeated skin abscesses with sinus tracts and scar formation. Currently, the aetiology and pathogenesis of hidradenitis suppurativa remain unclear. Genetic factors, immune disorders, hormonal abnormalities, skin-microbial dysbiosis, smoking, obesity and mechanical friction all influence hidradenitis suppurativa pathogenesis. Moreover, hidradenitis suppurativa has a familial subset with autosomal dominant transmission proposed and is related to a mutation of γ-secretase component genes. In this review, we analyse and summarise research progress regarding the relationship between the γ-secretase gene dysfunction and the pathogenesis of hidradenitis suppurativa.

This study aimed to determine whether the treatment of skin abscesses with vessel loop drainage is noninferior to standard incision and drainage (ID) regarding treatment failure in pediatric patients in the emergency department (ED).This study was a prospective, randomized controlled trial in a pediatric ED of an urban tertiary pediatric hospital. Patients with a skin abscess were enrolled. Subjects were assigned to the control arm of ID or the study arm of vessel loop drainage. Study end points (failure rates, satisfaction scores, wound appearance, visit frequency) were assessed before discharge from the ED, at 24- to 48-hour follow-up, and at 14-day follow-up. Treatment failure was declared if the abscess required reinstrumentation or admission for intravenous antibiotics for systemic illness within 14 days.From August 2014 to October 2015, 81 patients completed this study. Treatment failure was observed in 3 subjects of each arm (7.3% loop vs 7.5% standard; risk difference, 0.2%; 95% confidence interval, -11.2% to 11.6%). Parent satisfaction rates with wound appearance at day 14 were similar (86.1% loop vs 88.2% standard were at least satisfied). Median cosmetic scores were similar at day 14 (6 [interquartile range {IQR}, 5-6] loop vs 6 [IQR, 5-6] standard, where 6 was optimal). Follow-up visit frequency was similar (2 [IQR, 2-3] loop vs 2 [IQR, 2-2.5] standard).Abscess drainage with a vessel loop in the pediatric ED results in failure rates noninferior to those of the standard ID. Satisfaction and cosmetic scores are favorable in both groups.

Chronic granulomatous disease (CGD) is caused by a genetic defect in one of the five glycoproteins in the NADPH oxidase complex

Skin and skin structure infections caused by bacteria involve the skin layers and underlying connective tissue. Cellulitis and abscess are two of the most common manifestations of these types of infections. Streptococcus pyogenes (group A streptococcus) is the predominant cause of cellulitis, but Staphylococcus aureus should also be considered. S. aureus remains the most common cause of skin abscesses, and over the past few decades, methicillin-resistant S. aureus has become a leading pathogen. Less commonly, gram-negative bacteria and strict anaerobic bacteria are involved, becoming important pathogens to consider in settings of bite wounds, aquatic injuries and exposures, surgical wounds, and traumatic injuries. Infections caused by Pasteurella multocida are commonly associated with dog and cat bite wound infections, and Eikenella corrodens is a hallmark pathogen involved in human bite wound infections. Vibrio species and Aeromonas species are aquatic pathogens that cause severe necrotizing skin and soft tissue infections in patients with underlying risk factors such as chronic illness and immunodeficiency. Mycobacterium marinum, another aquatic pathogen, typically causes indolent, chronic granulomatous skin infections. Strict anaerobic bacteria and other gram-negative pathogens such as Pseudomonas aeruginosa are important causes of skin and skin structure infections in patients with underlying immunosuppression and comorbid conditions. Recurrent skin and soft tissue infections often prompt further evaluation for underlying immunodeficiency.

HLH-2004 criteria suggests that five of the following conditions is sufficient for clinical diagnosis of HLH: 1) fever above ≥38.5 °C, 2) splenomegaly, 3) peripheral blood cytopenia, 4) hypertriglyceridemia and/or hypofibrinogenemia, 5) proven hemophagocytosis in bone marrow, spleen, lymph node, or liver, 6) low or absent NK cell activity, 7) ferritin >500 ng/mL, and 8) elevated soluble CD25 (soluble IL-2 receptor alpha) Normal bone marrow biopsy is possible in primary HLH, as a result of the remission of HLH flare, previous treatment with corticosteroids or even as a normal finding

Povidone-iodine (PVP-I) antiseptic solutions have been shown to be effective against methicillin-resistant Staphylococcal aureus, a common cause of superficial skin abscesses.Our objective was to study the feasibility of using PVP-I as a treatment adjunct in patients with superficial skin abscesses and determine if it confers any benefit over incision and drainage (ID) alone.This was a randomized controlled pilot study of adult patients with an uncomplicated skin abscess. Patients were randomized to PVP-I or standard treatment. All patients had ID and abscess packing. Patients randomized to PVP-I were instructed on daily application of the agent to hands, wound, and surrounding skin with dressing changes. Subjects returned at 48-72 h and 7-10 days and followed-up by phone at 30 days. The primary outcome was clinical cure 7-10 days after ID. The secondary outcomes were rate of development of new skin lesions and spread in household contacts within 30 days.Clinical cure occurred in 91.3% of patients in the standard group vs. 88.2% of patients in the PVP-I group (difference, 3.1%; 95% confidence interval [CI] -10.7 to 16.8; p = 0.53). There was a significantly higher adverse event rate in the group who received PVP-I (59.6%) vs. standard care (26.5%) (difference 33.1%, 95% CI 13.2-50.2; p 0.001).There was no difference in clinical cure rates among patients using PVP-I (88.2%) vs. standard care (91.3%) after ID. There were no major adverse events, but the addition of PVP-I was commonly associated with local skin irritation.

Clinical question In patients with uncomplicated abscesses receiving incision and drainage, does the addition of trimethoprim-sulfamethoxazole result in improved clinical resolution at 7 to 14 days after treatment when compared with placebo? Article chosen Talan DA, Mower WR, Krishnadasan A, et al. Trimethoprim-sulfamethoxazole versus placebo for uncomplicated skin abscess. N Engl J Med 2016;374(9):823-32. Objective The primary objective of this study was to compare the clinical cure rates at 7 to 14 days after the end of the treatment period among patients receiving either trimethoprim-sulfamethoxazole (TMP-SMX) or placebo. Secondary outcomes included composite cure; surgical drainage procedures; change in erythema size; presence of swelling, induration, or tenderness; invasive infections; skin infections at the same site and different sites; hospitalizations; similar infections in household contacts; days missed from normal activities; days missed from school or work; and days of analgesic use.

Outcome assessments as clinical trial endpoints should be well-defined, reliable, and reflect meaningful treatment benefits. For acute bacterial skin and skin structure infections (ABSSSI) trials, recent recommendations suggest a primary endpoint of reduction in skin lesion area. Objectives were: evaluate ABSSSI lesion area measurement reliability, evaluate impact of various lesion area definitions on treatment effect size, and explore relationships between lesion area and pain.Data from two randomized, double-blinded Phase 3 trials comparing tedizolid to linezolid in ABSSSI and one open-label, non-comparative Phase 2 study of tedizolid in cellulitis/erysipelas and skin abscess were analyzed. Repeated lesion area measurements were prospectively obtained in all studies. In the open-label study, lesion area was measured by two investigators, using four different definitions. Repeated pain assessments using two patient-reported outcome instruments (Visual Analog Scale [VAS] and Faces Rating Scale [FRS]) were elicited in the randomized trials.At baseline, lesion size did not correlate with pain intensity: r=0.02 for VAS and r0.01 for FRS pain scores. However, decreasing lesion size and decreasing pain were strongly associated over time, regardless of initial lesion size or pain intensity (r=0.20 for VAS and r=0.21 for FRS scores at Day 10-13). Each lesion area definition demonstrated high inter-observer reliability (intra-class correlation coefficient0.95).Decreasing lesion area (indirect clinician-reported measure of benefit) and pain (direct patient-reported measure of benefit) were strongly associated over time, and lesion area measurements were reliable, regardless of their definition. These findings support both measures as outcome assessments in ABSSSI clinical trials.Clinicaltrials.govNCT01519778, NCT01170221, and NCT01421511.

An enlarged and hard right hind limb of a condemned lame pig from a local slaughterhouse was submitted to National Chung Hsing University for pathological examination on 29 May 2015. Gross examination revealed brush burn and skin abscess. The radiography of the affected foot showed enlarged hock joint, collapsed tarsal joint with bony proliferation, and a soft tissue mass extending from the lateral to the tarsal bones. After the sample was split between the third and fourth metatarsal bone longitudinally, the calcaneus, talus, and the fourth tarsal bone were shown to be broken and damaged. Histopathological findings were as follows. First, the fractured bones showed the formation of callus and multiple small bone fragments were found. Second, osteoclasts and osteogenesis with bone remodeling were discovered at the edge of the bone fragments. Third, the skin abscess showed well-encapsulated clumps of bacteria and cellular debris. Trueperella pyogenes was identified from skin abscess and bone marrow. We speculate that the neglected fractures might have been related to crush injury inflicted by a sow or possible damage caused by the floor of the crate. This case highlights the importance of maintaining a high standard of animal welfare and once a lesion has occurred in food-producing animals, medication or elimination should be considered to avoid the long-term suffering of the animals.

Management of common infections and optimal use of antimicrobial agents are presented, highlighting new evidence from the medical literature that enlightens practice. Primary therapy of staphylococcal skin abscesses is drainage. Patients who have a large abscess (>5 cm), cellulitis or mixed abscess-cellulitis likely would benefit from additional antibiotic therapy. When choosing an antibiotic for outpatient management, the patient, pathogen and in vitro drug susceptibility as well as tolerability, bioavailability and safety characteristics of antibiotics should be considered. Management of recurrent staphylococcal skin and soft tissue infections is vexing. Focus is best placed on reducing density of the organism on the patient's skin and in the environment, and optimizing a healthy skin barrier. With attention to adherence and optimal dosing, acute uncomplicated osteomyelitis can be managed with early transition from parenteral to oral therapy and with a 3-4 week total course of therapy. Doxycycline should be prescribed when indicated for a child of any age. Its use is not associated with dental staining. Azithromycin should be prescribed for infants when indicated, whilst being alert to an associated ≥2-fold excess risk of pyloric stenosis with use under 6 weeks of age. Beyond the neonatal period, acyclovir is more safely dosed by body surface area (not to exceed 500 mg/m(2)/dose) than by weight. In addition to the concern of antimicrobial resistance, unnecessary use of antibiotics should be avoided because of potential later metabolic effects, thought to be due to perturbation of the host's microbiome.

Purpose: To present the clinical features of the eyelid nodules observed in a newly determined dermatologic disorder, idiopathic facial aseptic granuloma (IFAG), and to compare them with children having acute hordeolum and chalazion. Methods: Duration of the lesion, localization, presence of coexisting facial nodules, management strategies, and response time to topical/oral antibiotics were retrospectively reviewed in 50 children with IFAG, acute hordeolum, or chalazion. Results: Fourteen children with one or more IFAG nodules on their eyelids, 28 children with one or more acute hordeolum, and 8 children with one or more chalazion were examined. Children with IFAG on their eyelids and face presented earlier than children with acute hordeolum ( P = .006). The duration of this lesion was similar among patients with IFAG on their eyelids and acute hordeolum ( P = .53). Duration of the lesion and treatment response time were shorter in children with IFAG on their eyelids and face ( P = .004) than in those with IFAG on their eyelids ( P = .013). The lesions of patients with chalazion had a longer duration compared to those with IFAG on their eyelids ( P = .005), IFAG on their eyelids and face ( P < .001), and acute hordeolum ( P = .04). Twenty patients with acute hordeolum recovered after topical antibiotics and had a similar treatment response time to those with IFAG on their eyelids and face ( P = .06) and those with IFAG on their eyelids ( P = .16). Conclusions: IFAG should be considered in the differential diagnosis of painless eyelid nodules in children. Because IFAG on the eyelids has many overlapping features with hordeola/chalazia, its differentiation may be difficult in the absence of accompanying facial granulomas. Chronic subepidermal eyelid nodules resembling skin abscess should alert clinicians for IFAG. Because IFAG responds well to oral clarithromycin, unnecessary surgical interventions should be avoided in these cases. [ J Pediatr Ophthalmol Strabismus . 2016;53(4):206–211.]

Introduction: This study describes and reports, for the first time, an outbreak of dermatophilosis that occurred concurrently with caseous lymphadenitis involving two camel herds (Camelus dromedaries) in north Jordan. Methodology: The affected animals were part of two herds comprising 52 Arabian camels in herd 1 and 65 camels in herd 2. The age of infected camels ranged from 18 months to 5 years. Pus and skin scab samples were aseptically collected and bacteriologically examined. Affected camels were treated by long-acting oxytetracycline injection in a dose rate of 10 mg/kg body weight every 48 hours for three successive treatments, and local antiseptic and antibiotic cutaneous spray treatment for five successive days. Results: The main clinical signs on affected camels were skin dermatitis and abscess formation. The isolated organisms were Dermatophilus congolensis and Corynebacterium pseudotuberculosis were the causative agents of dermatophilosis and caseous lymphadenitis, respectively. Other organisms were isolated from skin abscesses, including α-hemolytic streptococci, hemolytic E. coli, Actinomyces pyogenes, and S. aureus. The affected camels were rapidly and effectively cured by the above-mentioned treatment protocol. No mortality was recorded. Conclusions: Introducing purchased camels from animal auctions without pre-examination and keeping camels in over-crowded small barns under cold, humid, and rainy conditions during winter may predispose the eruption of mixed infection of dermatophilosis and caseous lymphadenitis. Treatment by long-acting oxytetracycline injection with local antiseptic and antibiotic cutaneous spray can control such infection. A survey on camel herds raised near Jordan’s borders is needed to monitor the possibility of emerging infectious disease.

In 2013 the US Food and Drug Administration (FDA) issued recommendations and guidance on developing drugs for treatment of skin infection using a new definition of acute bacterial skin and skin-structure infection (ABSSSI). The new classification includes cellulitis, erysipelas, major skin abscesses and wound infection with a considerable extension of skin involvement, clearly referring to a severe subset of skin infections. The main goal of the FDA was to better identify specific infections where the advantages of a new antibiotic could be precisely estimated through quantifiable parameters, such as improvement of the lesion size and of systemic signs of infection. Before the spread and diffusion of methicillin-resistant Staphylococcus aureus (MRSA) in skin infections, antibiotic therapy was relatively straightforward. Using an empiric approach, a β-lactam was the preferred therapy and cultures from patients were rarely obtained. With the emergence of MRSA in the community setting, initial ABSSSI management has been changed and readdressed. Dalbavancin, oritavancin and tedizolid are new drugs, approved or in development for ABSSSI treatment, that also proved to be efficient against MRSA. Dalbavancin and oritavancin have a long half-life and can be dosed less frequently. This in turn makes it possible to treat patients with ABSSSI in an outpatient setting, avoiding hospitalization or potentially allowing earlier discharge, without compromising efficacy. In conclusion, characteristics of long-acting antibiotics could represent an opportunity for the management of ABSSSI and could profoundly modify the management of these infections by reducing or in some cases eliminating both costs and risks of hospitalization.

We describe the case of an infant with recurrent episodes of staphylococcal skin abscess and subsequent lethal pneumococcal meningitis/septicemia due to interleukin-1 receptor-associated kinase 4 (IRAK-4) deficiency. In this case, systemic signs of inflammatory response were poor and delayed. Among all other reported cases of IRAK-4 deficiency, none involved severe viral or fungal disease, and the range of infecting bacteria was narrow.