Chronic Skin Infection Research Articles

Renal amyloidosis in intravenous heroin addicts with nephrotic syndrome and renal failure

Renal amyloidosis has emerged as an important differential diagnosis when heroin addicts are admitted to renal clinics with proteinuria and nephrotic syndrome. We present nine heroin addicts with renal AA amyloidosis, a condition previously not encountered in Norway, who were admitted to our renal clinic during the last 3.5 years. In the same time period a total of 209 patients were biopsied from native kidneys. Heroin abuse was associated with 70% of all biopsy-verified renal AA amyloidosis during this time period. Renal amyloidosis was found in 9 of the 12 heroin addicts that were biopsied. 6 of the 9 heroin addicts with amyloidosis required dialysis within 13 months after admission. Renal AA amyloidosis among heroin addicts seems to be associated with chronic suppurative skin infections. AA amyloidosis should always be considered in chronic heroin addicts presenting with proteinuria and renal impairment.

Histological diagnosis of madura foot (mycetoma): A must for definitive treatment

Mycetoma, an uncommon chronic infection of skin and subcutaneous tissues in tropical countries is caused by true fungi (eumycetoma) or by filamentous bacteria (actinomycetoma). Since the treatment of these two etiologies is entirely different, a definite diagnosis after histopathological and microbiological examination is mandatory. We hereby present five cases of Madura foot.

Chronic Varicella‐Zoster Skin Infection Complicating the Congenital Varicella Syndrome

Congenital varicella is a rare syndrome arising when a pregnant woman develops varicella before the 24th week of pregnancy. We report an occurrence of congenital varicella syndrome complicated by a chronic varicella zoster virus skin infection in an immunocompetent infant. The chronic verrucous skin infection is puzzling in our patient, as this disease is usually described in immunosuppressed patients.

Hidradenitis Suppurativa Presenting with a Posterior Neck Mass: A Case Report

Hidradenitis suppurativa is a rare disorder that is characterized by recurrent chronic skin infections and the formation of sinus tracts and considerable scaring. A 37-yearold man presented with a hard posterior neck mass. Multiple pus-producing sinuses were detected in the skin covering the mass. MRI demonstrated an ill-defined, soft tissue mass with multiple variable sized cystic lesions. The soft tissue mass measured 12 ×10×4 cm in the subcutaneous fat layer, it contained multifocal cystic lesions that revealed higher signal intensity on both the T1- and T2-weighted images, as compared with the adjacent neck muscles. The mass was not enhanced on the post-contrast T1 weighted images. Some of the cystic lesions extended to the skin. The mass was removed surgically and confirmed to be hidradenitis suppurativa.

Macrorestriction Analysis of Clinical and Environmental Isolates of Sporothrix schenckii

Sporothrix schenckii causes sporotrichosis, a disease that most commonly presents as a subacute or chronic skin infection. An unusually high incidence of clinical cases of sporotrichosis occurred in the southwest of Western Australia over the last 5 years. Anecdotal accounts from patients implicated contact with hay prior to infection. Isolates of S. schenckii from hay and clinical cases were investigated by traditional phenotypic methods and pulsed-field gel electrophoresis (PFGE). The phenotypic evaluation separated S. schenckii from Ophiostoma spp. A DNA macrorestriction method using SfiI and NotI macrorestriction digestion by PFGE was developed to investigate the epidemiological connections. BioNumerics software was used to analyze the results. DNA macrorestriction digestion patterns for the recent Western Australian clinical isolates and four hay isolates were indistinguishable. Eastern state clinical isolates, national Quality Assurance Program isolates, and other environmental isolates gave different macrorestriction patterns. Clinical isolates from the southwest of Western Australia collected in the 1980s and 1990s were also characterized using PFGE. The patterns generated were indistinguishable from those of the recent clinical isolates. PFGE showed that the dominant strain of S. schenckii causing sporotrichosis in Western Australia is present in hay, has caused sporotrichosis for at least 15 years, and is a different strain from the strains found in other parts of Australia.

The small colony variant (SCV) concept—the role of staphylococcal SCVs in persistent infections

The recovery of small colony variants (SCVs) from clinical specimens was first described at the beginning of the last century. However, not until the past decade was an association of these variants with chronic, recurrent, and persistent infections such as chronic osteomyelitis and persistent skin and softtissue infection described. Since then, a number of reports and prospective studies have supported a pathogenic role for SCVs in disease. Biochemical and other characteristics of SCVs have suggested a link between electron-transport defective SCV strains and persistent infections, however, the strains examined were genetically undefined SCVs. Therefore, a stable mutant in electron transport was generated by interrupting one of the hemin biosynthetic genes, hemB, in Staphylococcus aureus. This mutant showed characteristics typical of clinical SCVs such as slow growth, decreased pigment formation, low coagulase activity, reduced hemolytic activity, and resistance to aminoglycosides. Furthermore, the mutant was able to persist within cultured endothelial cells due to decreased a-toxin production. It was suggested that the intracellular location of this subpopulation might shield the variants from host defenses and antibiotics, thus providing one explanation for the difficulty in removing SCVs from host tissues. Therefore, a defect in the electron-transport system allows S. aureus SCVs to resist aminoglycosides and persist intracellularly. Because of their fastidious growth characteristics, they are easily missed or misidentified in the clinical laboratory. Therefore, when an infection persists for weeks or months or fails to respond to antimicrobial therapy, clinicians as well as laboratory personnel should consider further efforts to search for this staphylococcal subpopulation.

The Prevalence of Diagnosed Cutaneous Manifestations during Ambulatory Diabetes Visits in the United States, 1998–2002

Background: The prevalence of diabetes has been rapidly increasing. Previous reports indicated that diabetics are prone to certain cutaneous diseases. Objective: To determine the frequencies of diagnosed skin conditions during ambulatory diabetes visits in the USA. Methods: We evaluated two national ambulatory medical care surveys between 1998 and 2002 and compared the diagnoses of 7 categories of skin conditions in diabetics (n = 9,626) to patients with hypertension (n = 15,997) or gastroesophageal reflux disease (GERD; n = 2,362) using χ² tests and multivariate logistic regressions. Results: Diabetics were prone to chronic skin ulcers (odds ratio = 62.5, 95% confidence interval = 3.95–989 compared to GERD; 9.97, 6.34–15.7 compared to hypertension), bacterial skin infections (5.95, 2.86–12.4 compared to GERD; 5.15, 3.74–7.08 compared to hypertension) and fungal skin infections (2.66, 1.15–6.16 compared to GERD; 1.99, 1.32–3.01 compared to hypertension) but not to other skin conditions. These findings remained true during primary care physician visits. Conclusion: Chronic skin ulcers, bacterial and fungal skin infections are more frequently diagnosed in diabetics. We could not verify that other skin conditions are associated with diabetes, in part due to potential underdiagnosis and underreporting.

A case of Munchausen syndrome by proxy with subsequent suicide of the mother

Munchausen syndrome by proxy is a subtle and difficult to diagnose form of child abuse in which the carer (usually the mother) simulates, manipulates or produces symptoms of illness in the victim. In most cases the detrimental effect is caused by applying foreign substances or by airway obstruction. In the presented case a 20-month-old girl developed a spreading soft-tissue infection resistant to treatment on the left upper arm after vaccination, which required a number of surgical interventions. Repeatedly, microorganisms from the intestinal flora were isolated from the wound secretion. After the girl suffered respiratory and circulatory arrest, which required resuscitation measures, chemical toxicological tests revealed not medically prescribed benzodiazepines in serum and urine. When the mother, a trained nurse, was confronted with the allegation to have manipulated the symptoms of the illness she committed suicide. The forensic autopsy of the suicide produced numerous hints suggesting chronic self-damaging behaviour described as Munchausen syndrome. This case shows a number of manipulation forms with the maintenance of a chronic skin and soft tissue infection belonging to the rarer forms of inflicting damage to the child. It also illustrates that confrontation with the allegation of Munchausen syndrome by proxy creates a very stressful emotional situation that may lead to a suicidal act.

Micafunginが著効した慢性皮膚粘膜カンジダ症の1症例

Chronic mucocutaneous candidasis (CMC) is a chronic intractable infection of skin, nails, and mucous membrane with Candida. Until very recently, the main stay of therapy had been the use of transfer factor or antifungal azole derivatives. Although they show definite benefits, the effects are temporal and recurrences are inevitable. Furthermore, the prolonged use of antifungals will sometimes induce resistant strains, making the treatment more difficult. Recently we experienced a case of CMC caused by resistant Candida spp. and treated it successfully with a new antifungal agent, micafungin (MCFG). The patient is a 37-year-old woman. She was eight month, her tongue was covered with a white coat. Two months later, intractable cutaneous eruptions appeared on the head and back and the diagnosis of CMC was made. Since then she has been treated on multiple occasions with transfer factor, recombinant IL-2, ketoconazole or clotrimazole. She was referred to us because of esophageal candidiasis. On admission, oral and esophageal mucous membranes were thickly coated with white pseudomembranes. The titer of Candida antigen test was less than twice ; plasma beta-D-gulcan was 20.14 pg/mL ; and CD4 was 376/microL. A few Candida albicans and (1+) Candida glabrata were cultured from oral swab. Both species were resistant to itraconazole but sensitive to MCFG and amphotericin B (MIC: < 0.03microg/ml for both). A drip infusion of MCFG (75mg/day) was started and three days later the oral lesions disappeared. At the end of a 2-week course of i. v. MCFG, the interior of the esophagus was clear. No recurrence was noted in one month. Less toxic than amphotericin B, MCFG will be a drug of choice in patients infected with azole-resistant fungi. To avoid the abuse of MCFG and the development of the resistant strains, the susceptibility test is recommended in every case of systemic candidiasis.

Intracranial necrotizing granuloma caused by Cladophialophora bantiana

The dematiaceous fungi are a group of pigmented hyphal yeasts best known as agents of chronic skin and subcutaneous infections. Extracutaneous disease is exceptional. We report herewith a case of necrotizing granuloma caused by one member of the group, Cladophialophora bantiana. This organism is fully capable of invading the nervous system of apparently immunocompetent hosts and in many cases does so in the absence of demonstrable foci of extraneural infection. It has also been reported to be the most frequently found causative organism in the central nervous system phaeohyphomycosis. C. bantiana has several older names in the literature including Clodosporium trichoides, C. bantianum and Xylohypha bantiana. Patients require treatment with a combination of medical and surgical therapy. Rarity of the case and the usefulness of a simple diagnostic method such as smear cytology, which lead us to the diagnosis, is highlighted by the report.

Allergy and Dermatophytes

Tinea pedis (athlete's foot) and onychomycosis (infection of the toenails) caused by the dermatophyte fungus Trichophyton are highly prevalent in adults. Several Trichophyton allergens have been identified based on elicitation of immunoglobulin E antibody-mediated immediate-hypersensitivity (IH) responses. Evidence of an etiologic role for Trichophyton in asthma in some subjects with IH and chronic dermatophytosis is provided by bronchial reactivity to Trichophyton. Improvement of asthma after systemic antifungal treatment corroborates this link. A unique feature of Trichophyton allergens is the ability of the same antigen to elicit delayed-type hypersensitivity (DTH) in individuals who lack IH reactivity. Delayed responses appear to confer protection, while IH responses do not, based on the association with acute versus chronic skin infection. The amino acid sequence identity of Trichophyton allergens with diverse enzyme families supports a dual role for these proteins in fungal pathogenesis and allergic disease. Characterizing the immunologic properties of Trichophyton allergens and defining immune mechanisms which drive dichotomous responses are pivotal to understanding the dermatophyte-allergy relationship. Recent studies have identified DTH-associated major T-cell epitopes which could facilitate the development of peptide vaccines. Characterization of additional molecular targets by using new techniques may aid not only in the eradication of infection but also in the resolution of allergic symptoms.

A comparison of cefditoren pivoxil and amoxicillin/clavulanate in the treatment of community-acquired pneumonia: A multicenter, prospective, randomized, investigator-blinded, parallel-group study

Background: Cefditoren pivoxil is a broad-spectrum cephalosporin that is approved for the treatment of pharyngitis, acute exacerbations of chronic bronchitis, and skin and skin-structure infections. Objective: This study was conducted to examine the efficacy and tolerability of cefditoren in the treatment of community-acquired pneumonia (CAP). Amoxicillin/clavulanate was chosen as a comparator because of its established efficacy and general acceptance as a standard of care in CAP. Methods: This multicenter, prospective, randomized, investigator-blinded, parallel-group trial compared oral cefditoren 200 and 400 mg BID with oral amoxicillin/clavulanate 875/125 mg BID for 14 days in adult outpatients with CAP. Results: Eight hundred two patients (404 men, 398 women; mean age, 50 years; age range, 12–93 years) with CAP were enrolled. Comparable clinical cure rates were observed among evaluable patients in all treatment groups at both the posttreatment and follow-up visits: 88.0% (125/142) for cefditoren 200 mg, 89.9% (143/159) for cefditore 400 mg, and 90.3% (130/144) for amoxicillin/clavulanate at the posttreatment visit, and 86.5% (128/148), 86.8% (138/159), and 87.8% (129/147) for the respective groups at the follow-up visit. Of 82 Streptococcus pneumoniae strains isolated before treatment, 22 (26.8%) had reduced susceptibility to penicillin, 12 (14.6%) of them penicillin resistant. Overall eradication rates at the posttreatment visit for pathogens isolated from microbiologically evaluable patients were 84.0%, 88.6%, and 82.6% for cefditoren 200 mg, cefditoren 400 mg, and amoxicillin/clavulanate, respectively. In the respective treatment groups, 80.6%, 88.6%, and 88.0% of Haemophilus influenzae strains and 95.0%, 96.2%, and 89.5% of S pneumoniae strains were eradicated. The rates of resolution of or improvement in clinical signs and symptoms were comparable between treatment groups. The treatment regimens were well tolerated, with 4.9%, 3.0%, and 5.2% of patients in the respective treatment groups requiring discontinuation of study drug due to an adverse event. Conclusions: In this study in adult outpatients with CAP, both doses of cefditoren demonstrated equivalence to amoxicillin/clavulanate based on rates of clinical and microbiologic cure. All 3 regimens were effective in resolving or improving the clinical signs and symptoms of CAP. Both cefditoren and amoxicillin/clavulanate were well tolerated.

The significance of nasal carriage of Staphylococcus aureus as risk factor for human skin infections

The present study was designed to investigate the significance and the relationship between nasal carriage of Staphylococcus aureus and staphylococcal skin infections. Thirty-one S. aureus strains, isolated from 12 patients with chronic and recurrent skin infections, one patient with septicemia and one patient with otitis externa were studied. The staphylococcal strains were isolated from the site of infection and from the anterior nares of each patient. The identity of both strains of each pair could be demonstrated by determination of phenotypic properties and by genotyping of the isolates. The phenotypic properties included hemolytic activities, antibiotic resistance data, and the production of enterotoxins. The identity was additionally confirmed by phage-typing, by determination of the size and the number of repeats of the X region of spa gene, by determination of gene polymorphisms of coa gene and by macrorestriction analysis of the chromosomal DNA of the isolates by pulsed-field gel electrophoresis. The present results showed an identity of the S. aureus obtained from anterior nares and from skin infection of each patient indicating the importance of nasal carriage of these bacteria for development of human skin infection.

The significance of nasal carriage of Staphylococcus aureus as risk factor for human skin infections.

The present study was designed to investigate the significance and the relationship between nasal carriage of Staphylococcus aureus and staphylococcal skin infections. Thirty-one S. aureus strains, isolated from 12 patients with chronic and recurrent skin infections, one patient with septicemia and one patient with otitis externa were studied. The staphylococcal strains were isolated from the site of infection and from the anterior nares of each patient. The identity of both strains of each pair could be demonstrated by determination of phenotypic properties and by genotyping of the isolates. The phenotypic properties included hemolytic activities, antibiotic resistance data, and the production of enterotoxins. The identity was additionally confirmed by phage-typing, by determination of the size and the number of repeats of the X region of spa gene, by determination of gene polymorphisms of coa gene and by macrorestriction analysis of the chromosomal DNA of the isolates by pulsed-field gel electrophoresis. The present results showed an identity of the S. aureus obtained from anterior nares and from skin infection of each patient indicating the importance of nasal carriage of these bacteria for development of human skin infection.

Rats injected with syngenic rat apoptotic neutrophils develop antineutrophil cytoplasmic antibodies.

Antineutrophil cytoplasmic antibodies (ANCA) are present in sera from patients with various forms of vasculitis-associated glomerulonephritis. Because autoantibodies may be directed against antigens presented by apoptotic cells, generation of ANCA using apoptotic neutrophils (PMN) in syngenic Brown Norway (BN) rats was attempted. These rats are T-helper type 2-prone animals, already used successfully in other ANCA-positive animal models. BN rats received repeated injections of buffer or of nonapoptotic or apoptotic PMN aged in cultures, in the footpad and once intravenously. Four of five rats that received injections of PMN aged for 48 h developed ANCA, which cross-reacted with human leukocyte elastase in three cases. None of the rats that received injections of freshly isolated neutrophils developed ANCA. One rat that received buffer injection and that exhibited chronic skin infection developed delayed ANCA. None of the rats showed signs of disease: no weight loss and no proteinuria. Then a subnephritogenic dose of antibody directed against rat glomerular basement membrane was injected. Rats then were killed, and different organs were frozen and studied. No significant lesions were found in kidneys or lungs. It is concluded that injections of apoptotic but not freshly isolated PMN can generate ANCA in BN rats. Additional studies are needed to elucidate the immunization mechanism and the ability of these autoantibodies to initiate vasculitis in these experimental animals.

Back Pain and Immunosuppression: What's at the Root of it All?

A32-year-old woman with systemic lupus erythematosus (SLE) on immunosuppressive medications presented to the Walter C Mackenzie Health Sciences Centre, Edmonton, Alberta, with a three-day history of right wrist swelling. She also complained of chronic midthoracic back pain in the setting of documented steroid-induced osteoporosis. Her back pain had increased over the six months before admission. She had also developed bilateral radicular pain, limited mobility, leg weakness, urinary hesitancy and a subjective change in light touch sensation of the legs. Bowel function was normal. She had night sweats but no fever or weight loss. There was no history of travel outside Alberta nor was there animal exposure. When well, the patient worked as a teacher’s aide. There was no personal or exposure history to suggest past tuberculosis (TB) infection. She was admitted for investigation, pain control and wrist aspiration. Past medical history was notable for Staphylococcus aureus joint infections, steroid-induced diabetes, shingles, remote pulmonary embolism, chronic recurrent skin and soft tissue infections, and a Salmonella dublin bacteremia 10 months before this admission. Medications at admission included prednisone, chloroquine, cyclophosphamide, metformin and hydromorphone. Physical examination revealed a pale, afebrile woman in moderate discomfort. Respiratory, cardiac and abdominal examinations were within normal limits. Musculoskeletal examination revealed an ‘exaggerated thoracic kyphosis’ at approximately T8. Joint examination was normal with the exception of decreased range of motion at the right wrist secondary to swelling, with minimal erythema and tenderness. Limb strength and reflexes were equal, with downgoing plantar responses. Admission laboratory data were as follows: hemoglobin 107 g/L, platelets 400×10/L, white blood cells 4.3×10/L with lymphocytes of 0.4×10/L. Serum urea and creatinine were normal. Serum transaminases, bilirubin and the international normalized ratio were within normal limits and the alkaline phosphatase was elevated at 157 IU. Complement levels were low and the sedimentation rate was 43 (mm/h). On admission and subsequently, the blood cultures were all negative. The right wrist aspirate revealed a small amount of noninflammatory fluid, which was negative on Gram stain and culture. A bone scan was performed, which revealed diffuse increased uptake in both wrists, consistent with an ‘arthritic process’, and there was ‘intensely increased’ uptake in the

Nutritional support for children with epidermolysis bullosa

The term epidermolysis bullosa (EB) describes a number of rare, genetically determined blistering disorders characterized by excessive fragility of the skin and mucous membranes. Complications in the mouth, oesophagus and anus, combined with chronic skin infections and blood loss can severely compromise nutritional intake , leading to prolonged malnutrition and extreme growth failure. However, with early nutritional assessment and intervention, it is possible to achieve substantial improvements in nutritional status and growth, benefiting a variety of aspects of quality of life and reducing morbidity and mortality. In severe cases, attempts to enhance oral intake alone fail to promote satisfactory growth, and placement of a button gastrostomy device is the treatment of choice. In a multisystem condition such as EB, the success of dietary manipulations invariably depends on satisfactory management of a number of related factors—notably chronic constipation, gastro-oesophageal reflux and skin care. To promote appropriate strategies of intervention, it is highly advantageous for the dietitian to understand the aetiology and prognosis of the different types of EB, and to operate as an integral and pro-active member of the large multidisciplinary team required to manage these children.

N04. Chronic Skin Infections

Australasian Journal of DermatologyVolume 38, Issue S2 p. 25-26 Interactive Contributions to Clinical and Experimental Dermatology N04. Chronic Skin Infections First published: 22 June 2017 https://doi.org/10.1111/ajd.1997.38.s2.25AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume38, IssueS2June 1997Pages 25-26 RelatedInformation

Imbalance of immune responses in patients with chronic and widespread fungal skin infection

Fungal infections of the skin are caused by dermatophyte fungi. Infections can be acute and inflammatory or chronic and non-inflammatory; it is believed that cell-mediated immunity is the cornerstone of host defence and is instrumental in the eradication of the infection. We describe here parameters of the immune response of a group of patients who although not immunocompromised, suffered from widespread and chronic infections. All patients lacked a specific delayed-type hypersensitivity (DTH) response; however, their in vitro lymphocyte proliferation in response to Trichophyton rubrum extract and to other fungal antigens was normal. The patients were not atopic by clinical history, and yet had high levels of non-specific IgE and of T. rubrum-specific IgG4. Taken together, the results of this study suggest that the group of patients studied suffered from an immune imbalance which has characteristics of a Th2-type response.

DERMATOLOGIC MANIFESTATIONS OF NONTUBERCULOUS MYCOBACTERIAL DISEASES

Various nontuberculous mycobacteria can cause infection of skin and soft tissues. These organisms are also known as atypical mycobacteria, anonymous mycobacteria, and mycobacteria other than tuberculosis. These organisms are much more common causes of cutaneous infection than Mycobacterium tuberculosis. Infections caused by nontuberculous mycobacteria are frequently misdiagnosed because clinicians fail to include them in the differential diagnosis of chronic skin infection.