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Background Community-acquired methicillin resistant Staphylococcus aureus (CA-MRSA) infections have been increasing. The most common of these infections present as skin abscesses. The objectives of this study were to prospectively determine the prevalence of CA-MRSA in abscesses in the population of a pediatric emergency department, to determine antibiotic sensitivity patterns of the CA-MRSA isolates, and to describe the patient population that presented with skin abscesses. Methods We conducted a prospective study of children under the age of 18 years who presented to our pediatric emergency department with a skin abscess that required incision and drainage. Pus from these abscesses was sent for culture to determine the causative agent, and antibiotic sensitivities were reported. Characteristics of the patient population that presented with these abscesses were examined. Results Sixty-eight patients were enrolled over an 18-month period. Of these, 60 (88%) had cultures positive for Staphylococcus aureus (S. Aureus). Of these 60 patients, 51 (85%) were identified as CA-MRSA by their resistance patterns. All of the CA-MRSA isolates were sensitive to trimethoprim/sulfamethoxisole; 6 (10%) were either resistant or intermittently resistant to clindamycin. Limitations The study was conducted on a convenience sample of patients and enrolled a relatively small number of patients. Conclusions CA-MRSA is responsible for the vast majority of skin abscesses presenting to the pediatric emergency department. CA-MRSA isolates are likely to be sensitive to trimethoprim/sulfamethoxisole or clindamycin, although there is some resistance to clindamycin.

The identification of different bacterial strains and the occurrence of antibiotic resistance were investigated in several infection processes of pets as skin abscess with purulent discharge, bronco alveolar fluid, earwax, urine, mammary, and eye fluid. Streptococcus spp. and Staphylococcus spp. were the most detected in the different samples. A high frequency of antimicrobial resistance has been observed and this could reflect the wide use of antimicrobials in pets, making the effectiveness of antibiotic treatment to become more complicated.

Fournier's gangrene (FG) is a rare, rapidly progressive, fulminant form of necrotizing fasciitis of the genital, perianal and perineal regions. Several factors have been reported to contribute to the clinical outcomes. The primary aims of this study were to examine the clinical features of patients with FG and evaluate the predictivity of the Fournier's Gangrene Severity Index (FGSI) score on the outcomes. We carried out a collective retrospective chart review of patients diagnosed and treated for FG in three reference centers between January 1995 and July 2007. Seventy-two patients with FG with were included to the study. Data were collected on medical history, symptoms, physical examination findings, admission and final laboratory tests, timing and extent of surgical debridement and antibiotic therapy. Perianal and perirectal abscess, scrotal abscess and urethral stenosis were the leading etiological factors. Diabetes mellitus was the predominant risk factor. Etiological factors and risk factors did not significantly contribute to survival or mortality, and duration of the symptoms was significantly longer in the non-survivor's group (P < 0.05). The FGSI scores were higher in the non-survivor's group. Regression analysis showed a FGSIS score of 10.5 as the cut-off to the outcome. Based on these results, we conclude that a patient's metabolic status and the extent of disease at presentation are the most important factors determining the prognosis of FG. The FGSI score may be considered as an objective and simple tool to predict the outcome in the patient with FG and should be used in further studies of FG patient series for comparison purposes. © Springer Science+Business Media, B.V. 2008.

A retrospective clinical and immunological survey was conducted in 60 patients with Chronic Granulomatous Disease. A prospective controlled non-randomized study of the efficacy of long-term IFNgamma treatment was carried out. The mean age at the time of diagnosis was 4.4 years; mean duration of follow-up was 10.4 years. Lung and skin infections were the most frequent manifestations both prior to diagnosis and during follow-up. Aspergillus species was the first cause of infection and of death in our cohort. The mortality rate was 13%. Long term prophylaxis with IFNgamma did not significantly change the rate of total infection per patient-year compared to controls (p=0.07). Our data provide clear evidence that protocols of continuing intensive surveillance and monitoring of compliance with anti-infective regimens may significantly improve the quality of life and long-term survival in patients with CGD. No evidence justifying long-term prophylaxis with IFNgamma was obtained.

Methicillin-resistant Staphylococcus aureus (MRSA) infections have become more common over the last decade. Recently, severe MRSA infections including necrotizing pneumonia, purpura fulminans, and rapidly progressive skin abscesses have been reported. These severe infections frequently have been associated with the virulence factor Panton-Valentine leukocidin (PVL). Two unusual cases of occult deep tissue abscesses in children who had family members with a history of severe MRSA skin abscesses are presented in this article. Both children initially presented with fever without a focus. Deep tissue MRSA (PVL positive) abscesses evolved. Empiric antibiotic therapy for MRSA should be considered for infants and children who are hospitalized with occult fever and who have a family member with a history of MRSA infection.

This study was designed to determine the validity of a central eschar with surrounding cellulitis as a clinical predictor for CA-MRSA infection. In this 10-month prospective observational study, patients with a chief complaint or clinical findings of skin infection with abscess had study data sheets placed on their chart. All abscesses were treated with incision and drainage, and wound cultures were obtained. Exclusionary criteria included patient age under 18 years, recently incarcerated within 14 days, and hospitalized or in a nursing home within 10 days. Correlation of wound culture results with recorded physical examination determined the sensitivity, specificity, and positive/negative predictive values. A total of 224 patients with abscesses were enrolled; 18 patients met exclusion criteria. An additional 78 patients were excluded because no wound cultures had been obtained, study data form was incomplete, or there was no evidence of wound cellulitis. Of the 128 remaining patients, 91 wound cultures grew MRSA (71% prevalence). Of these 91 cases, 50 tested positive for central black eschar, yielding a sensitivity of 55% (95% confidence interval [CI] 0.45-0.65). Thirty-seven patients had abscesses that grew non-MRSA bacteria. Three of these were positive for central black eschar, yielding a specificity of 92% (95% CI 0.83-1.01). The positive predictive value was 94% (95% CI 0.88-1.01) and the negative predictive value was 45% (95% CI 0.32-0.59). A central black eschar with cellulitis has good specificity and high positive predictive value in diagnosing CA-MRSA infection.

Hyperimmunoglobulin E syndrome (HIES) with recurrent infection is a rare primary immunodeficiency characterized by the clinical triad of recurrent staphylococcal abscesses, cyst-forming pneumonia and an elevated serum immunoglobulin (Ig)E level. We report an 18-year-old man with recurrent chest infections, skin infections and dermatitis. On examination, he had the characteristic facies of HIES: high arched palate, webbing between his thumb and index finger bilaterally, and extensive scarring from multiple staphylococcal skin abscesses. He had an elevated IgE level of 14 300 kU/L. IgA and IgG deficiencies were also identified, which are rare associations of this syndrome and complicated the patient's treatment. The coexistence of HIES, IgA and IgG deficiencies has, to our knowledge, not been reported previously in the literature.

Forty-nine children with skin abscesses (36 methicillin-resistant Staphylococcus aureus and 13 methicillin-susceptible S. aureus) exhibited similar disease severity. Both pathogen groups were pulse field type USA300, multilocus sequence type 8, and possessed Panton-Valentine leukocidin genes. Related microbial genetic architecture may account for similarities in disease severity despite differences in antibiotic susceptibility.

Background Hyperimmunoglobuline E syndrome (HIES), also known as Job Syndrome, is a rare primary immuneodeficiency disorder characterised by recurrent eczema, skin abscesses, lung infections, eosinophilia and high serum level of IgE. Two forms of HIES have been described, type 1(Autosomal Dominant) and type 2 (Autosomal Recessive) which is more severe. These two forms share overlapping clinical and laboratory features. However, they also exhibit distinct clinical manifestations, courses and outcomes. This paper will present our experience with this rare disease in our new Immunology unit. Methods Six cases were diagnosed between end 2008 to early 2014, depending on clinical features, laboratory and radiological evaluation. Results Two cases of HIES presented before their second birthday and the other four before their fifth. Two cases were brothers. Male to female ratio was 2:1. Each case initially presented with different chronic infections. All have coarse features, eczema, high IgE (>2500 iu/ml), high eosinophil count and recurrent oral thrush. Five of the six cases have onychomycosis. Three cases had extensive varicella eruption. Infections were treated according to the international guidelines. Chest x–ray showed lung cysts in two cases, three cases had no lung changes and one patient refused x–ray and any follow up. Echocardiogram was normal in five cases. Serum Immunoglobulins, T and B lymphocyte subset were normal for four cases. The other two cases, one of them showed low T helper cell and low CD4 percentage with normal total count, and the other case showed low natural killer cell CD56 percentage and high count CD19, CD4, CD8, CD3 with normal percentage. All cases were put on oral prophylactic Trimethoprim and regular follow up except one who refused (Figure 1). Conclusion The rising awareness among junior doctors and early referral of cases with symptoms to suggest primary immunodeficiency disorders help to diagnose and treat cases of HIES (Job Syndrome) which used to be missed and arrived to hospital in serious or terminal state. The incidence rate of Job syndrome internationally is rare. Further studies are needed to estimate the incidence rate and prevalence in different areas of our country.

A 57-year-old end stage renal disease patient on hemodialysis (HD) presented with sepsis secondary to right buttock abscess and overlying cellulitis. She was started on broad-spectrum antibiotic therapy and underwent incision and drainage with marked improvement. Her cultures grew methicillin-resistant Staphylococcus lugdunensis. This bacterium is more virulent than other coagulase negative staphylococci and has been implicated in causing a variety of serious infections but it has been underreported as a cause of skin infections in HD patients and possible other patient populations.

Job's syndrome or hyper-immunoglobulin E syndrome (HIES) is a heterogeneous complex of immunodeficiencies distinguishes by skin abscesses, recurrent pneumatoceles or staphylococcal infections, high serum immunoglobulin E levels and eczematous dermatitis. It has two types depends on type of gene involved; autosomal-dominant HIES (AD-HIES), which develops due to signal transducer and activator of transcription 3 gene and autosomal recessive HIES caused by DOCK8 gene mutation. Hereby we present a case of 13-month-old male child who admitted to our hospital with pustular lesions on the neck, face and upper chest associated with itching; some of these were hemorrhaged and crusted. The complete clinical presentation and lab investigations have confirmed AD-HIES syndrome. The therapeutic strategy was directed mainly toward the prevention and management of infections and symptoms. This case presents the clinical features, investigational procedures and management strategy for that particular condition in pediatrics.

To ascertain the microbiology of skin abscesses, emergency department records were reviewed to identify patients with debrided skin abscesses. Methicillin-resistantStaphylococcus aureuswas isolated from 255 (67.6%) of 377 culture samples from episodes in the adult cohort and from 145 (79.7%) of 182 culture samples from episodes in the pediatric cohort. Thus, empirical use of contact precautions for patients with skin abscesses should be strongly considered.

Background Cloxacillin is a semisynthetic penicillin widely used in nonmethicillin resistant Staphylococcus aureus infections. Several hypersensitivity reactions to cloxacillin have been reported, although IgE-mediated allergic reactions to the drug are rare and there is little information about possible tolerance to other semisynthetic penicillins or cephalosporins in patients with cloxacillin allergy. We present 2 patients with demonstrated IgE-mediated allergy to cloxacillin and tolerance to amoxicillin and cefuroxime. Case reports Case 1. A 47-year-old woman began treatment with cloxacillin due to acute cellulitis. After ingesting 500 mg of the drug, she experience generalized maculopapular eruption and facial angioedema. Case 2. A 55-year-old woman presented an episode of acute urticaria and labial angioedema 60 minutes after ingesting 500 mg of cloxacillin for a skin abscess. Methods and results Skin prick tests were positive to cloxacillin in case 1 and negative in case 2. However, an intradermal test was positive to cloxacillin (2 mg/ml) in case 2. Simple-blind oral challenge tests with amoxicillin (1 g) and cefuroxime (500 mg) were well-tolerated by both patients. Conclusions We present 2 patients allergic to cloxacillin with normal tolerance to other betalactam antibiotics, confirming that cross-reactivity among these antibiotics seems to be uncommon. Complete allergy study, including an oral challenge test, should be considered in these patients.

Cutaneous metastasis (CM) is an uncommon manifestation of visceral malignancies. Adenosquamous carcinoma of the gallbladder is a rare variation in gallbladder carcinoma (GBC), associated with worse prognosis. We present the case of a 56-year-old woman who presented with an inflamed lump on her abdominal wall. Computed tomography (CT) revealed a large mass from the gallbladder invading the abdominal wall. She underwent liver resection with regional lymphadenectomy. Pathology analysis revealed a 12-cm pT3N0 GBC. Hospital discharge occurred at post-operative Day 20. She recurred and died 10 months after surgery. Survival after the diagnosis of CM is dismal. The present case was a diagnostic trap. First, the patient's skin lesion presented as a cutaneous abscess and biopsy revealed a squamous cell cancer. A CT scan suggested a continuous mass involving the abdominal wall. CM was only suspected during surgery when no continuity between the tumour and the abdominal wall was identified.

IntroductionSkin abscesses are common in emergency departments. Collectively, skin and soft tissue infections are the third most common diagnosis after chest pain and asthma.1 Emergency residents and fellows, as well as primary care physicians need to develop competency with abscess identification a

Myiasis is the infestation of skin by the larvae of flies. In North America cases are caused by the botfly ( Cuterebra ) and occur most commonly in children. The usual presentation is a subcutaneous abscess, and for this reason these patients may be referred to surgeons. Knowledge of this entity can avoid delays in diagnosis, unnecessary incision and drainage procedures, and unnecessary courses of antibiotics.

When considering common bacterial diseases of the skin, rather distinct clinical responses to a variety of bacterial infections have been identified. In these cases, it is the specific site of infection and the attendant inflammatory responses that provide the characteristic clinical picture. When the pyoderma extends just below the stratum corneum, it is called impetigo. Nonbullous impetigo is the most common pediatric skin infection. It usually starts in a traumatized area. The typical lesion begins as an erythematous papule, after which it becomes a unilocular vesicle. When the subcorneal vesicle becomes pustular, it ruptures and eventually becomes a yellow, golden crust that is a hallmark of the disease process. Bullous impetigo is a less common form of impetigo, accounting for fewer than 30% of all impetigo cases. It occurs in infants and is characterized by rapid progression of vesicles to the formation of bullae measuring larger than 5 mm in diameter in previously untraumatized skin. Treatment of nonbullous impetigo must include intervention against the pathogen as well as improvements in the hygiene and living conditions of the patient. A fundamental tenet is to debride the crust (scab) from the wound surface using poloxamer 188. If the lesions are not widespread, topical mupirocin is the treatment of choice. Treatment of bullous impetigo is similar, except that the local cleansing and topical antibiotic must be complemented by systemic antibiotics if there is evidence of disseminating infections. Ecthyma is usually a consequence of failure to treat effectively impetigo. The untreated infection extends deep into the tissue in shallow ulcerations that often heal without scar. Treatment for ecthyma usually requires systemic antibiotics against either staphylococcus or streptococcus. Folliculitis is a pyoderma located within a hair follicle, secondary to follicular occlusion by keratin, overhydration, or either bacterial or fungal infection. Folliculitis may be divided into either a deep or a superficial type. In the superficial type, the pustule is located at the opening of the hair follicle. In the deep form, the infection may extend beyond the confines of the hair follicle, becoming a furuncle or boil. Carbuncles are aggregates of interconnected furuncles that drain through multiple openings of the skin. Treatment of folliculitis must include searching for and avoiding any factors predisposing to infection. If topical antibiotic therapy is ineffective in controlling the infection, surgical drainage of the infected skin abscess will be necessary. Paronychia is the most common bacterial infection of the hand, which often requires surgical incisional drainage. Similarly, a felon that is an infection of the distal pulp of a finger usually requires surgical drainage. Finally, cellulitis is an acute inflammatory reaction involving the skin and underlying subcutaneous tissue. It usually starts as erysipelas and may advance to lymphangitis, lymphadenitis, or gangrene,which will respond to life-saving interventions in the hospital that usually include systemic antibiotic treatment as well as surgical intervention.

Aspergillus candidus, a common contaminant of grain dust, may represent an important respiratory hazard to grain workers, considering its immunomodulating capability by producing p-terphenyl metabolites and terprenins, potent cytotoxic substances. However, there are only three cases of A. candidus infection in the English literature, one fatal solitary brain mass and two onychomycosis. We describe the first case of invasive pulmonary infection and skin abscesses due to A. candidus, determination of minimal inhibitory concentration for anti-fungals, and the successful treatment with liposomal amphotericin B and itraconazole. Possible mechanisms involved in the dissemination of infection in an immunocompetent host are discussed.

“I know it when I see it . . . ,” as Justice Potter Stewart famously said of hard-core pornography. Would that this were the case with cellulitis. In principle, cellulitis is simply defined as an acute infection with inflammation of the skin involving the dermis and subcutaneous tissues. In practice, because of the overlapping signs and symptoms of skin infections, the terminology has become burdened with terms such as erysipelas, purulent cellulitis, nonpurulent cellulitis, nonsuppurative cellulitis, cellulitis with drainage, cellulitis with ulcer, cellulitis with abscess, abscess with surrounding cellulitis, and necrotizing cellulitis (to name a few), in an effort to parse differences in microbiology, severity, and prognosis that may impact therapy and management. At the semantic other extreme is International Classification of Diseases, Ninth Revision coding, which lumps cellulitis and abscess together, even though these 2 entities would appear to be easily differentiated clinically and microbiologically. Clearly, an abscess is a collection of pus often in association with pain, swelling, and inflammation. Whatever cellulitis is, it is not an abscess, as there is no collection of pus, which, if there were, the lesion would be an abscess and not cellulitis. Presence of a collection of pus affords the clinician great comfort, diagnostically and therapeutically. It is abscess defining, and culturing it permits a precise microbiological diagnosis. By far the most common cause of skin abscesses (barring unusualexposuresorinjurysuchasbrackishwaterorbites)isStaphylococcusaureus, andpusand abscessformationare its modus operandi. Treatment is quite straightforward: Drain the pus, all of it. If an antimicrobialisneeded(atopicthatiswell

We present the case of a 60-year-old patient who developed a right-sided bilothorax following para-aortic lymph node sampling. Bilothorax is a very rare condition, with most of the reported cases resulting from direct flow of bile from the biliary system to the pleural space through a fistula or other defect in the diaphragm. In this case, there was no obvious communication found between peritoneal and pleural spaces. Our patient proceeded to an exploratory laparotomy following this finding in the absence of peritonitis. Bilothorax should be considered in patients who develop a progressive pleural effusion following upper gastrointestinal surgery, particularly if it involves manipulation of the biliary system.

A 42-year old Italian male with type 2 diabetes and HCV-related chronic hepatitis spent 6 months in Thailand. After his return in June 2002 he was admitted to the Infectious Diseases Unit of the Hospital of Livorno (Italy) because of fever, chest pain and skin abscesses in the legs. Chest X-rays and CT scan revealed multiple bilateral cavitary lesions in the lungs. Ultrasonography and CT scan showed numerous subcentimetric spleen abscesses. Burkholderia pseudomallei was isolated from the cutaneous lesions and sputum and thus melioidosis was diagnosed. A 6-week course of i.v. ceftazidime plus oral doxycycline was given during the acute phase of the illness. The in vitro susceptibility testing showed that long-term (20 weeks) antimicrobial therapy with doxycycline and moxifloxacin was required. Complete resolution of pulmonary and spleen lesions was obtained within 6 weeks of therapy and of cutaneous abscesses in 10 weeks. No significant side effects were noted during the follow-up period using this scheme of antimicrobial therapy.

Although Acinetobacter is usually a species of low virulence, it is becoming increasingly more important as a cause of hospital outbreaks, particularly on intensive care units. Antibiotic resistance can develop rapidly. This organism has not been reported to cause skin abscesses previously. We describe a case of a neonate who developed an Acinetobacter abscess on our neonatal intensive care unit.

Psoas abscess is uncommon in childhood. It has an insidious onset, and diagnosis and management may be delayed because of non-specific symptoms and signs. A 12-day-old male infant was referred to hospital with skin abscesses and fever. He was born at 39 weeks gestation as the first child of consanguineous parents. His birthweight was 2600 g and there was no history of premature rupture of membranes or maternal fever. His maternal uncle died at 20 days of age due to an unknown cause. On admission, he had a 3 ¥ 3 cm swelling on the medial side of his left ankle, a 0.5 ¥ 0.5 cm swelling on his left hand and a nodule on the lateral side of the left ankle. Laboratory findings were as follows: leukocyte count 26 900/ mm (62% neutrophils, 38% lymphocytes); C-reactive protein 31.3 mg/dL and erythrocyte sedimentation rate 85 mm/h. The abscesses were drained and vancomycin and ceftazidime were initiated. Culture was positive for methicillin-susceptible Staphylococcus aureus. On the seventh day of admission, fever of 38.5°C and swelling and hyperemia on the right groin appeared. On ultrasonography (US) 10–14 mm hypoechoic fluid was seen on the right side of the bladder. Tuberculin skin test, salmonella, brucella, and HIV were negative. Magnetic resonance imaging (MRI) of the abdomen showed an 38 ¥ 16 ¥ 14 mm abscess formation with ring enhancement on the right inguinal region. The patient underwent percutaneous drainage but the drainage material contained very few polymorphonuclear leukocytes without microbiological growth. Antibiotic treatment was continued and follow-up US showed complete resolution of the abscess. On immunological work up, serum immunoglobulins and lymphocyte subset analysis were in the normal range according to age (Table 1). Phagocytic cell functions were also normal on nitroblue-tetrazolium (NBT) slide test. Flow cytometry results were as follows: CD18, 16%; CD11a + CD18, 17%; CD11b + CD18, 3%; CD11c + CD18, 4%. Neutrophil function was determined as 1.89 oxidative explosion, 1.63 phagocytosis and 1.43 chemotaxis (normal, >1.5). Antibiotic prophylaxis was initiated and bone marrow transplantation was recommended. Diagnosis of psoas abscess is difficult in neonates because of the rarity of this disease and the difficulty in differentiating this from septic arthritis due to similar clinical findings. Good physical examination is critical for prompt diagnosis. US and computed tomography are the preferred radiological tests for diagnosis. Psoas abscess in children may be primary or, rarely, secondary to an underlying pathology of kidney, cecum, appendix, or terminal ileum on the right side and fever. Neonates and children may have an antecedent or contemporaneous distant cutaneous infection. The causes of psoas abscess have changed in the last decades. In recent years S. aureus has been reported as the causative agent in 80% of primary psoas abscesses. Early drainage with appropriate systemic antibiotic coverage is the ideal treatment. Drainage of the abscess may be done through US-guided percutaneous drainage or surgical drainage. After complete abscess drainage up to 2 weeks of broad spectrum antibiotic treatment should be started pending culture results. Predisposing conditions to primary psoas abscess development are reported to be HIV infection, diabetes, immunosuppression and renal failure. Based on flow cytometry, the present patient was diagnosed with leukocyte adhesion deficiency type 1 (LAD 1; mild type). In conclusion, immunodeficiency syndromes such as LAD should be investigated in newborns with psoas abscess. The present case is important to emphasize underlying factors in the pathogenesis of psoas abscess.

Cutaneous abscesses are an uncommon manifestation of Acanthamoeba infection. We report a case of a patient with acquired immunodeficiency syndrome who developed multiple cutaneous lesions on his arms, legs, and trunk. Skin biopsies revealed cysts and trophozoites of Acanthamoeba spp with invasion of blood vessel walls associated with tissue necrosis. Brain lesions examined at autopsy failed to reveal amoeba and no other foci of amoebic infection were found.

Background. Cutaneous infection with Mycobacterium fortuitum, a ubiquitous rapid growing atypical mycobacterium, most often occurs as a postsurgical wound complication or at the site of a penetrating injury to the skin. Rarely, disseminated infection with cutaneous involvement can occur in immunocompromised patients. Case Report. A 47-year-old black woman presented with a 10-year history of numerous draining abscesses and tender nodules on the back and buttocks unresponsive to oral and intravenous antibiotics. Biopsy showed a granulomatous and suppurative dermatitis and panniculitis and special stains did not reveal organisms. M. fortuitum was cultured from involved skin on two separate occasions. The patient improved with a 2-week course of intravenous amikacin and cefoxitin combined with oral probenecid followed by a course of doxycycline and ciprofloxacin. Conclusions. Widespread primary cutaneous infection with M. fortuitum may occur in an immunocompetent patient. Chronic draining skin abscesses unresponsive to routine antibiotics may represent infection with an atypical mycobacterium; tissue cultures of affected skin should be performed to rule out this possibility. Therapy should be directed by culture sensitivity results.

Neisseria cinerea is bacteria known as non-pathogenic strain. However, in rare cases, it can cause opportunistic infections. Those diseases caused by N. cinerea include neonatal ophthalmia, proctitis, pneumonia, peritonitis in patients with continuous ambulatory peritoneal dialysis, endocarditis and meningitis. In this report, we describe a patient with septic arthritis and skin abscess of finger joints that was caused by N. cinerea . A 27-year-old man visited the hospital due to swelling, redness and pain of proximal interphalangeal joint of the left second finger. After blood culture test, ceftriaxone was administered on admission and debridement was performed the affected joints. N. cinerea was identified in the blood culture. The patient was improved with ceftriaxone.

A 40-year-old man with a history of schizophrenia and inflammatory soft tissue lesions after self-injection of elemental mercury presented to the Emergency Department. Multiple skin abscesses associated with fever required operative debridement. An incidental finding of oral mercury ingestion was followed clinically and did not result in complications. Exposure to elemental mercury through injection or ingestion is an uncommon event, but one the Emergency Physician may encounter. Subcutaneous mercury injection should be managed with local wound debridement, whereas ingestions are rarely of clinical significance.

Commentary on: GR Schmitz, D Bruner, R Pitotti, et al.. Randomized controlled trial of trimethoprim–sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection.Ann Emerg Med. 2010;56:283–7.

Commentary on: M Duong, S Markwell, J Peter, et al.. Randomized, controlled trial of antibiotics in the management of community-acquired skin abscesses in the pediatric patient. Ann Emerg Med2010;55:401–7.

Gram-positive organisms are the most common infectious etiologic agents in skin abscesses. Empiric antimicrobial treatment choices are influenced by this knowledge. In this report, we describe a high prevalence of Proteus mirabilis, a Gram-negative bacillus, in skin abscesses of the axilla, which has potential implications for selection of antimicrobial therapy.

Pyogenic liver abscesses are rarely encountered in HIV-infected patients living outside of temperate climates and are usually polymicrobial in nature, with a majority of the pathogens arising from gastrointestinal flora. We describe the second case of a liver abscess in an HIV-positive individual that was caused by methicillin-resistant Staphylococcus aureus (MRSA), most likely due to a partially treated community-acquired MRSA skin abscess. The liver abscess was successfully managed by percutaneous drainage and intravenous antibiotics. This case underlines the ubiquitous nature of community-acquired MRSA and its possible unusual presentations in immunocompromised hosts.

Background: Injectable collagen has been used for more than 15 years to correct soft tissue cosmetic defects. After injection, the collagen remaining in the syringe is often refrigerated for later use in the same patient, despite manufacturer and Food and Drug Administration recommendations to discard the unused collagen. Objective: This study examined the incidence of bacterial contamination of stored collagen. Methods: Syringe needle tips and collagen from 50 previously used syringes containing either Zyderm I, Zyderm II, or Zyplast were cultured separately under aerobic and anaerobic conditions. Bacterial isolates were identified. Results:Propionibacterium acnes was cultured from 7 of 50 needle tips. One positive needle tip culture grew both P. acnes and Staphylococcus aureus. Bacteria were isolated from only one collagen sample that grew a nonhemolytic streptococcus that may have represented a laboratory contaminant. Conclusion: Syringes of collagen stored for repeated use rarely become contaminated with bacteria despite frequent contamination of their needle tips. Skin abscesses after collagen injection should be cultured under anaerobic, as well as aerobic, conditions so that infections caused by P. acnes will not be missed.

Objective: To examine whether select bacterial infections are associated with HTLV-II infection among injection drug users, we conducted a nested case control study within an ongoing cohort study. Method: HTLV-II status was determined by enzyme-linked immunosorbent assay, immunofluorescent assay, and immunoblot. Diagnosis of bacterial pneumonia, infective endocarditis, and skin abscess was confirmed by standardized chart reviews, Three sets of cases were identified based on diagnosis of bacterial pneumonia, infective endocarditis validated by chart review, or self-reported skin abscess. Each case was matched to a minimum of 5 controls by age, HIV status, and study follow-up duration. Risk factors for each bacterial infection were analyzed separately by conditional logistic regression methods. Results: Prevalence of HTLV-II infection ranged from 7% to 11% in cases and controls. The bivariate association of HTLV-II and bacterial pneumonia revealed an odds ratio (OR) of 1.1 (95% confidence interval [CI], 0.6-2.0); the association of infective endocarditis and HTLV-II revealed an OR of 1.7 (95% CI, 0.7-3.9); and the association between HTLV-II and skin abscess revealed an OR of 1.3 (95% CI, 0.6-2.0). These ORs were unaltered by adjustment for other factors. Conclusion: Our results suggest that these three bacterial infections were not significantly associated with HTLV-II infection within a population of injection drug users. Additional associations between HTLV-II infection and disease outcomes merit further exploration.

1. Anjali Jain, MD* 2. Robert S. Daum, MD* 1. 2. *Department of Pediatrics, Sections of General Pediatrics and Infectious Diseases, the University of Chicago, Chicago IL. After completing this article, readers should be able to: 1. List the toxins and virulence factors that allow Staphylococcus aureus to be a highly virulent pathogen for children. 2. Define the important host defense mechanisms against staphylococcal infection. 3. Describe appropriate evaluation and therapy of a child who has a red and swollen eye. 4. Describe the clinical syndromes of impetigo, indicate how their etiologies differ, and delineate the appropriate diagnosis and management of each. 5. Describe the management of a febrile child who has an indwelling central venous catheter. It was more than a century ago that the Scottish surgeon Alexander Ogdson initially noticed an association between skin abscesses and an organism that formed clusters of“ berries” when seen by light microscopy. Today, we designate this organism Staphylococcus aureus , the most pathogenic of the genus Staphylococcus , and know that it is responsible for many serious community-acquired and nosocomial infections and for several more recently recognized toxin-mediated diseases. The defining characteristics of this species are the production of the extracellular enzyme coagulase and protein A. Staphylococci that do not produce these proteins are termed coagulase-negative staphylococci (CoNS); they were once believed to be nonpathogenic constituents of normal human bacterial flora, but we now appreciate that they also are important causes of nosocomial and urinary tract infections in children. Colonization with S aureus occurs intermittently in children; 10% to 40% are colonized, as are about 30% of adults. The most common site for colonization is the anterior nasal vestibule. Additionally, the skin, hair, nails, axillae, perineum, or vagina (in about 10% of menstruating women) may be colonized. Hospital personnel and individuals who have chronic skin conditions or medical devices (eg, indwelling catheters) have a higher rate of S aureus colonization than do individuals in the community. Unlike S aureus , CoNS colonize human skin …

An HLA-B27 positive, 18-year-old male patient was diagnosed with X-linked chronic granulomatous disease (CGD) two years after developing recurrent bronchitis and skin abscesses. He had multiple infections including fungal pneumonia, hepatic abscesses and CGD-associated colitis treated with intensive immunosuppression. His ophthalmic history included bilateral, recurrent anterior uveitis controlled with topical corticosteroids, and bilateral chorioretinal scarring. His last ophthalmic examination revealed bilateral keratoconjunctivitis and anterior uveitis with fibrin deposition on the anterior lens capsule (fig 1A). There were multiple oval regions of choroidal and retinal …

Sirs: We were greatly interested in the short illustrated review article by M. Turgut [4] entitled “Complete recovery of acute paraplegia due to pyogenic thoracic spondylodiscitis with an epidural abscess”. It presents a case of staphylococcal spinal epidural abscess with excellent outcome after surgical treatment. We want to report another patient with the same diagnosis and outcome, who underwent a conservative therapeutic approach. A 58 year old febrile man was admitted with an asymmetrical pure motor flaccid tetraparesis that had developed over 2 days. His past medical history was unremarkable. A skin abscess of the left gluteal region due to intramuscular injections was observed. Proper investigation excluded any factor correlated with immunodeficiency. At the initial neurological examination non symmetric pure motor flaccid tetraparesis was found. MRI of the spine showed discitis–osteomyelitis of C5–

ted to the outpatient clinic of our Institute for the treatment of an extensive tumour on her right cheek (Figures 1a and 1b). Histological examination of the biopsy sample confirmed planocellular carcinoma. Six years ago, she developed a minor skin abscess on the right cheek which was cured by electrodesiccation and curettage. Three years later, a tumour started to grow on the same spot of the right cheek. Until first appointment at the outpatient clinic, the tumour grew up to the size of 13 x 8 cm. The patient was declining any medical help from fear of pain. She was treated with irradiation by telecobalt unit, with a dose equivalent of 70 Gy. Three months after the beginning of Radiol Oncol 2008; 42(1): 13-4. doi:10.2478/v10019-007-0033-6

Subcutaneous candidal abscess is a very rare infection even in immunocompromised patients. Some cases are reported when breakdown in the skin occurs, as bacterial cellulites or abscess, iatrogenic procedures, trauma and parenteral substance abuse. We describe a case of Candida albicans subcutaneous abscess without fungemia, which can be associated with central venous catheter.