Infectious Cellulitis Research Articles

Fatal borealpox in an immunosuppressed patient treated with antivirals and vaccinia immunoglobulin - Alaska, 2023.

Borealpox virus (BRPV, formerly known as Alaskapox virus) is a zoonotic member of the Orthopoxvirus genus first identified in a person in 2015. In the six patients with infection previously observed BRPV involved mild, self-limiting illness. We report the first fatal BRPV infection in an immunosuppressed patient. A man aged 69 years from Alaska's Kenai Peninsula was receiving anti-CD20 therapy for chronic lymphocytic leukemia. He presented to care for a tender, red papule in his right axilla with increasing induration and pain. The patient failed to respond to multiple prescribed antibiotic regimens and was hospitalized 65 days postsymptom onset for progression of presumed infectious cellulitis. BRPV was eventually detected through orthopoxvirus real-time polymerase chain reaction testing of mucosal swabs. He received combination antiviral therapy, including 21 days of intravenous tecovirimat, intravenous vaccinia immunoglobulin, and oral brincidofovir. Serial serology was conducted on specimens obtained posttreatment initiation. The patient's condition initially improved with plaque recession, reduced erythema, and epithelization around the axillary lesion beginning one-week post-therapy. He later exhibited delayed wound healing, malnutrition, acute renal failure, and respiratory failure. He died 138 days postsymptom onset. Serologic testing revealed no evidence the patient generated a humoral immune response. No secondary cases were detected. This report demonstrates that BRPV can cause overwhelming disseminated infection in certain immunocompromised patients. Based on the patient's initial response, early BRPV identification and antiviral therapies might have been beneficial. These therapies, in combination with optimized immune function, should be considered for patients at risk for manifestations of BRPV.

Patterns of Antibiotic Prescription in Endodontic Therapy in the Republic of Croatia.

In response to the global trend of decreasing antibiotic usage, this study aimed to evaluate the nature and frequency of antibiotic prescriptions in conjunction with endodontic therapy in Croatia and to assess the attitudes of Croatian dental practitioners towards the endodontic treatment of patients susceptible to bacterial endocarditis. A survey questionnaire was sent to all dental practitioners in Croatia, achieving a response rate of 27%. The most frequently prescribed antibiotic was penicillin with clavulanic acid (63.4%), while standalone penicillin was less prevalent (18.6%). For patients exhibiting penicillin allergies, 90% of respondents indicated clindamycin as their preferred alternative. Antibiotics were mostly prescribed for localized acute apical abscesses without fever, followed by prophylaxis for infectious endocarditis and cellulitis. Only 1.3% of the respondents reported frequent antibiotic prescriptions without accompanying local treatment. While a substantial proportion of surveyed practitioners professed familiarity with the latest guidelines for antibiotic prophylaxis, their choice of antibiotics did not consistently reflect this claim. Most respondents conducted endodontic procedures on patients at risk of bacterial endocarditis. The findings highlight a need for targeted continuing education for dental practitioners in the Republic of Croatia, ensuring their practices align with current guidelines and global trends in antibiotic prescription.

Management of Acute Organic Change of Character cases by Liaison Psychiatry Unit

IntroductionThe Acute Organic Change of Character (AOCC) is an organic mental disorder subtype in which perception, thought, mood and personality impairment predominate. It consists in a change in the individual’s general behaviour or attitude, which is shown to be closely associated with or caused by an underlying organic process, and which is rapidly resolved when the organic noxious agent is eliminated (Pintor et al. Journal of Psychiatry and Psychiatric Disorders 4 (2020): 354-358).ObjectivesTo describe the importance of taking AOCC diagnosis into consideration and the role of liaison psychiatrists in AOCC management by presenting two AOCC cases admitted to the Hospital Clinic of Barcelona.MethodsWe retrospectively reviewed two AOCC cases in patients followed by our hospital’s liaison psychiatry unit during the summer of 2023. We also searched for previous case reports of AOCC using a PubMed query.ResultsCase 1: A 50-year-old male who suffered a polytrauma with diffuse axonal injury (DAI). His relatives and the referring medical team observed a change in his behaviour consisting in irritability, suspicion, hostility and impatience. No cognitive impairment nor fluctuation in the described symptoms were observed. At the time of discharge character changes were still present due to DAI slow and unpredictable clinical course. Symptomatic treatment with risperidone 6mg/day and quetiapine 100mg/day was administered achieving a satisfactory clinical response.Case 2: A 47-year-old woman with type 2 diabetes who suffered an infectious cellulitis that spread causing sepsis. The patient began to appear disruptive with verbose and tangential speech during her admission. No cognitive impairment nor fluctuation in the described symptoms were observed. Symptomatic treatment with risperidone 10mg/day and olanzapine 5mg/day was administered achieving a satisfactory clinical response. At the time of discharge character changes described before were almost resolved.ConclusionsThe clinical presentation of both cases suggested organic mental disorders in which a change in general behaviour predominates. Liaison psychiatrists play a key role in AOCC management by recognizing the clinical pattern, helping if needed with psychopharmacological treatment and ensuring a good understanding of the disorder both by the referring medical team and the patient’s relatives. To our knowledge, it would be of great importance to achieve a better understanding of this clinical condition which to date we consider to be underdiagnosed.Disclosure of InterestNone Declared

An itchy mystery: A rare case of Wells syndrome

Eosinophilic cellulitis (Wells syndrome) is an inflammatory dermatitis that is often misdiagnosed as infectious cellulitis due to its similarity in presentation. Misdiagnosis leads to delay of correct treatment and inappropriate use of antibiotics. The clinical eruption is characterized by varying morphology and severity and usually follows a relapsing remitting course. The classical histopathologic picture is of eosinophilic infiltrate of the dermis along with the presence of “flame figures.” Limited number of cases have been reported in the literature. We describe one such case which posed as a diagnostic dilemma.

Skin lesions as an initial manifestation of late osteosynthesis‐associated infection

AbstractLate osteosynthesis‐associated infection (OAI) is an uncommon and potentially serious disease. Its clinical presentation may mimic skin and soft tissue infection, leading to misdiagnosis. We report the case of a 64 year‐old man with a late OAI in the frontal bone, initially misdiagnosed as an infectious cellulitis. Late OAI can be difficult to suspect, especially if the intervention was performed years ago. Because of misdiagnosis, the symptoms can be masked by the use of antibiotics, so it is of utmost importance to take a detailed clinical history to make an early diagnosis and avoid potential complications. The treatment consists of the use of antibiotics and the replacement of the osteosynthesis material. Therefore, when facing a skin and soft tissue infection of torpid evolution which persists despite correct treatment and a past medical history of underlying osteosynthesis material, late OAI should be considered.

Metastatic neuroendocrine tumor masquerading as orbital cysticercosis.

Orbital metastases secondary to neuroendocrine tumors are exceedingly rare. We present a unique case of a 30-year-old female initially presenting with fever, chills, periorbital swelling, and painful proptosis. CT orbits revealed two ovoid-shaped ring-enhancing lesions in the right lateral and superior rectus muscles and clear sinuses, atypical for infectious post-septal cellulitis. Further work-up included serologic analysis, auto-immune panel, and MRI. Further imaging showed pseudocystic orbital lesions mimicking orbital cysticercosis. Additionally, given the bilateral nature of the lesions and patient's country of origin, this parasitic process was highly suspected. A course of albendazole and steroids led to resolution of symptoms. With a presentation at age 30, this is by far the youngest case reported in literature to date.

Eosinophilic Dermatosis of Hematological Malignancy Mimicking Wells Syndrome

Wells syndrome, also known as eosinophilic cellulitis, is an inflammatory dermatitis that is often misdiagnosed as infectious cellulitis, leading to the inappropriate use of antibiotics and a delay appropriate treatment. We present a diagnostically challenging case where a 65-year-old male with a known case of SLL was found to have eosinophilic dermatosis of hematological malignancy after a thorough workup. Although the association between CLL and Wells syndrome is well established, we have not encountered any similar association or other cases of Wells syndrome associated with SLL in the literature. The pathophysiology underlying the association between eosinophilic cellulitis and CLL/SLL remains incompletely understood, and further investigation is warranted.

Automated delineation of orbital abscess depicted on CT scan using deep learning.

To develop and validate a deep learning algorithm to automatically detect and segment an orbital abscess depicted on computed tomography (CT). We retrospectively collected orbital CT scans acquired on 67 pediatric subjects with a confirmed orbital abscess in the setting of infectious orbital cellulitis. A context-aware convolutional neural network (CA-CNN) was developed and trained to automatically segment orbital abscess. To reduce the requirement for a large dataset, transfer learning was used by leveraging a pre-trained model for CT-based lung segmentation. An ophthalmologist manually delineated orbital abscesses depicted on the CT images. The classical U-Net and the CA-CNN models with and without transfer learning were trained and tested on the collected dataset using the 10-fold cross-validation method. Dice coefficient, Jaccard index, and Hausdorff distance were used as performance metrics to assess the agreement between the computerized and manual segmentations. The context-aware U-Net with transfer learning achieved an average Dice coefficient and Jaccard index of 0.78±0.12 and 0.65±0.13, which were consistently higher than the classical U-Net or the context-aware U-Net without transfer learning (P<0.01). The average differences of the abscess between the computerized results and the experts in terms of volume and Hausdorff distance were 0.10±0.11mL and 1.94±1.21mm, respectively. The context-aware U-Net detected all orbital abscess without false positives. The deep learning solution demonstrated promising performance in detecting and segmenting orbital abscesses on CT images in strong agreement with a human observer.

Non-Necrotizing Acute Dermo-Hypodermal Infections: Erysipela and Infectious Cellulitis

Non-necrotizing acute dermo-hypodermal infections are infectious processes that include erysipela and infectious cellulitis, and are mainly caused by group A β-haemolytic streptococcus. The lower limbs are affected in more than 80% of cases and the risk factors are disruption of cutaneous barrier, lymphoedema and obesity. Diagnosis is clinical and in a typical setting we observe an acute inflammatory plaque with fever, lymphangitis, adenopathy and leucocytosis. Bacteriology is usually not helpful because of low sensitivity or delayed positivity. In case of atypical presentations, erysipela must be distinguished from necrotizing fasciitis and acute vein thrombosis. Flucloxacillin and cefradine remain the first line of treatment. Recurrence is the main complication, so correct treatment of the risk factors is crucial.

Circulating Secretory Phospholipase A2 Activity following Snakebites and Its Relationship with Envenomation Status and Progression of Local Swelling.

We studied whether circulating secretory phospholipase A2 (sPLA2) activity reliably distinguished patients with snakebite envenomation from those with nonvenomous/dry snakebites, and whether patients with progressive local swelling had persistence of circulating sPLA2 activity despite antivenom treatment. We prospectively enrolled adults presenting to the emergency with a history of snakebite in the past 24 hours. We estimated circulating sPLA2 activity at baseline before antivenom administration and after 48 hours in those with envenomation. We enrolled 52 patients with snakebites (mean age 39.3 ± 12.6 years; 35 [67%] men), and 16 patients with infective cellulitis as controls. Thirty patients had local ± systemic envenomation; 15 were classified as dry/nonvenomous bites; and envenomation status was unclear in seven patients. Baseline sPLA2 activity was significantly higher in snakebite patients than that in those with infective cellulitis (4.64 [3.38-5.91] versus 3.38 [1.69-4.01] nmol/minute/mL; P = 0.005). Among patients with snakebites, sPLA2 activity in the highest quartile was significantly associated with envenomation (12 of 27 versus two of 22; P = 0.010). However, median sPLA2 activity did not differ significantly between patients with envenomation and the rest. Baseline sPLA2 activity was significantly associated with the maximum extent of limb swelling (P = 0.031 for trend). In envenomed patients, circulating sPLA2 activity significantly decreased after 48 hours compared with the baseline (5.49 [3.38-8.86] versus 3.38 [2.53-4.64]; P = 0.003) including those with progressive swelling. Although circulating sPLA2 activity was elevated following snakebites, its sensitivity to diagnose envenomation appears to be limited. Administration of more antivenom after systemic manifestations had reversed might not benefit patients with progressive local swelling.

The effect of malnutrition on the infectious outcomes of hospitalized patients with cirrhosis: analysis of the 2011-2017 hospital data.

In patients with cirrhosis, there is a clinical concern that the development of protein-calorie malnutrition will affect the immune system and predispose these patients to increased infectious outcomes. In this study, we evaluate the effects of malnutrition on the infectious outcomes of patients admitted with cirrhosis. This study used the 2011-2017 National Inpatient Sample to identify patients with cirrhosis. These patients were stratified using malnutrition (protein-calorie malnutrition, cachexia, and sarcopenia) and matched using age, gender, and race with 1:1 nearest neighbor matching method. The endpoints included mortality and infectious outcomes. After matching, there were 96 842 malnutrition-present cohort and equal number of controls. In univariate analysis, the malnutrition cohort had higher hospital mortality [10.40 vs. 5.04% P < 0.01, odds ratio (OR) 2.18, 95% confidence interval (CI) 2.11-2.26]. In multivariate models, malnutrition was associated with increased mortality [P < 0.01, adjusted odds ratio (aOR) 1.32, 95% CI 1.27-1.37] and infectious outcomes, including sepsis (P < 0.01, aOR 1.94, 95% CI 1.89-2.00), pneumonia (P < 0.01, aOR 1.68, 95% CI 1.63-1.73), UTI (P < 0.01, aOR 1.39, 95% CI 1.35-1.43), cellulitis (P < 0.01, aOR 1.09, 95% CI 1.05-1.13), cholangitis (P < 0.01, aOR 1.39, 95% CI 1.26-1.55), and clostridium difficile (P < 0.01, aOR 2.11, 95% CI 1.92-2.31). The results of this study indicate that malnutrition is an independent risk factor of hospital mortality and local/systemic infections in patients admitted with cirrhosis.

Orbital Pseudocellulitis: A Retinoblastoma-Associated Masquerade Syndrome

Introduction: A masquerade syndrome is an atypical presentation of a neoplastic process that mimics an inflammatory condition. In this paper, we focus on orbital pseudocellulitis. Case Series: Our case series includes 5 retinoblastoma patients with orbital pseudocellulitis at presentation. In 3 patients the disease was bilateral, in 1 trilateral, and in 1 unilateral. The eyes with pseudocellulitis were enucleated, while the fellow eyes were treated conservatively, when affected. Four patients responded well to the therapy and showed remission of the tumor. The patient with trilateral retinoblastoma did not respond to therapy and died of disease. Discussion: Differential diagnosis with infectious orbital cellulitis is extremely important. Patients with orbital cellulitis present with fever, sinusitis, leukocytosis, and raised inflammatory markers, while ophthalmoscopic examination is negative and imaging studies show sinus involvement. On the contrary, patients with retinoblastoma do not show systemic inflammation, while ophthalmoscopic examination reveals leukocoria, buphthalmos, and an intraocular tumor mass associated with retinal detachment. Magnetic resonance imaging shows intralesional calcifications and soft tissue edema without sinus involvement. Histology confirms the diagnosis. Conclusions: Medical history, physical examination, and imaging studies are crucial in the diagnosis of retinoblastoma-associated orbital pseudocellulitis. Retinoblastoma should be excluded in all patients with signs of pre-septal orbital cellulitis through fundoscopy and/or imaging studies

Non-medial infectious orbital cellulitis: etiology, causative organisms, radiologic findings, management and complications

BackgroundOrbital cellulitis is an ophthalmic emergency, which is associated with vision-threatening adverse effects. The purpose of this study is investigating etiology, radiologic findings, management and complications of patients with non-medial orbital cellulitis.MethodA retrospective medical record and radiologic file review of patients with infectious orbital cellulitis was performed to detect all patients with non-medial orbital cellulitis who referred to Khalili hospital from 2016 to 2019. Age, sex, origin of infection, size of collection or abscess, medical or surgical management, microbiology, first and final best-corrected visual acuity, duration of admission, and complications was recorded. Patients divided into two groups; medical management and surgical management groups and all of data compared between in this groups.ResultsOf ninety-six patients with infectious orbital cellulitis, 23 cases (14 male, 9 female) were included. Five patients (21.7%) were managed medically and 18 patients (78.3%) were managed surgically. Patients’ age range was 5–70 years old. Most common location for non-medial cellulitis was superior space (66.7% in surgical and 40% in medical group; p = 0.511). In 13 cases of surgical group (72.3%) were detected microorganisms. The mean ± SD of collection volume in medical group were 476.5 ± 290.93 mm3 and 2572.94 ± 1075.75 mm3 in surgical group (p < 0.001). Ten patients in surgical group had compressive optic neuropathy. The mean ± SD of collection volume was 3204.97 ± 879.88 mm3 in patient with compressive optic neuropathy and 1280.43 ± 880.68 mm3 in patient without compressive optic neuropathy (P < 0.001). One case complicated by subdural empyema and another case progressed to necrotizing fasciitis.ConclusionNon-medial orbital cellulitis is an uncommon but sight-threatening and life-threatening condition. Timely diagnosis and accurate management reduce morbidity and mortality. Combined surgery for patients with superior or supra-temporal and large non-medial abscess is recommended.

LUMPS AND BUMPS: A COMMON COMPLAINT WITH SINISTER IMPLICATIONS

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: It is exceedingly uncommon for malignancy to present as cutaneous metastases. In fact, cutaneous metastases as an initial manifestation of internal neoplasias represent only 0.8% of total cases; and implies, in general, aggressive disease and poor prognosis. We present an atypical manifestation of non-small cell lung cancer (NSCLC) initially presenting as tender cutaneous nodules. CASE PRESENTATION: Patient is a 69 year-old female with pertinent medical history of 70 pack-year tobacco abuse who presented with a complaint of multiple painful, ulcerating skin nodules. 2 months prior to admission, she was seen by her physician for skin lesions and was prescribed a short course of antibiotics without resolution. At admission, patient reported a 1 month history of fatigue, unintentional 15 pound weight loss, and diffuse myalgias. Initial vital signs revealed normal temperature, heart rate of 113 bpm, respiratory rate of 16 breaths per minute, saturating 97% on room air. Labs revealed leukocytosis at 19.8 k/mm3 and lactic acid level of 3 mmol/L. She was suspected to have sepsis secondary to cellulitis. She was given 30 mg/kg fluid bolus and started on broad spectrum antibiotics. On examination, she had multiple ulcerated subcutaneous skin nodules on her chest, abdomen, inguinal area, and scalp. Radiographic imaging revealed a large left upper lobe mass with extensive pulmonary nodules concerning for malignancy. Imaging of her head revealed numerous supra and infratentorial metastatic lesions. Punch biopsy of a skin nodule was taken. Immunohistochemical (IHC) testing was positive for pankeratin and cytokeratin 7, but were negative for any neuroendocrine markers. Biopsy and IHC were consistent with poorly differentiated non-small cell lung adenocarcinoma. DISCUSSION: Cutaneous involvement among patients diagnosed with NSCLC is a rare finding, affecting 2.8%. Even less uncommon as the initial presenting symptom. Patterns of cutaneous metastases vary among women and men. Breast cancer, colorectal cancer, and melanoma frequently metastasize to the skin in women. In men; melanoma, lung cancer, and colorectal cancer are the most common sources of cutaneous metastases. Cutaneous metastases can present asymptomatically or be associated with pain and tenderness. Furthermore, they can often be mistaken for inflammatory dermatosis, infectious cellulitis, bullous or papulosquamous lesions. CONCLUSIONS: While rare, cutaneous manifestation can be the first sign of metastatic disease and often purports a poor prognosis. Therefore, it is important to recognize and evaluate abnormal skin lesions in the correct clinical context with appropriate clinical measures such as history, physical exams, imaging, and biopsy with histochemical staining. Reference #1: Alkhayat H, Hong CH. Cutaneous Metastases from Non-Small Cell Lung Cancer. J Cutan Med Surg. 2006 Nov-Dec;10(6):304-7. Reference #2: Ardavanis A, Orphanos G, Ioannidis G, Rigatos G. Skin Metastases from Primary Lung Cancer. Report of Three Cases and a Brief Review. In vivo. 2001; 20(5):671-3. Reference #3: Baldeo C, Ali R, Seeram V, House J. Lung Cancer Presenting as Soft-Tissue Metastasis. Case Rep Oncol. 2015;8:185-188. DISCLOSURES: No relevant relationships by Brandon Cherry, source=Web Response No relevant relationships by Menalee Hapuarachchi, source=Web Response No relevant relationships by Machaiah Madhrira, source=Web Response No relevant relationships by Harsh Patel, source=Web Response

Time Does Not Heal All Wounds

Introduction: This is a case of pyoderma gangrenosum presenting 14 years after procto-colectomy for ulcerative colitis(UC). Response to oral steroids and wound therapy was suboptimal warranting use of anti-TNF therapy. Case presentation: A 61-year-old female with history of UC s/p procto-colectomy 14 years ago, and orthotopic liver transplant for primary sclerosing cholangitis (maintained on sirolimus) presented with a non-healing ulcerated wound on the left medial calf. The wound started as a blister and progressed to a 20x10x2cm ulcer with elevated violaceous borders.Despite initial concerns for infectious cellulitis, response to multiple prolonged courses of antibiotics was marginal. Given history of inflammatory bowel disease and wound characteristics, pyoderma gangrenosum was suspected. Wound biopsy showed vascular thrombosis with extensive necrobiotic changes and foci of acute inflammation was nonconclusive. Sirolimus was held to allow for wound to heal. Poor wound healing persisted despite three weeks on high dose prednisone. Patient was then started on infliximab, and the wound showed marked improvement after a few weeks of therapy. However thereafter, family decided to proceed with hospice care, mainly because of decline in mental status of unclear etiology. Discussion: Pyoderma gangrenosum(PG) is a rare cutaneous manifestation of UC and Crohn's disease. It has a course independent of the underlying disease activity. Traditionally treatment consisted largely of local wound care and topical and systemic steroids. Topical tacrolimus and oral cyclosporine have also been used as single agents or more commonly as combination therapy with steroids. Surgical debridement may actually worsen disease and is best avoided. Recently the role of biologics has been explored. PG is associated with the upregulation of several pro-inflammatory cytokines including IL-8, TNF, and interferon gamma, among many others, which may explain the response anti-TNF agents. Level of evidence supporting use of these agents is variable. Randomized controlled trials support the use of prednisolone, cyclosporine, and infliximab. Decision on using a particular agent will depend on wound extent, local expertise and associated comorbidities (for patients with concomitant active inflammatory bowel disease for example, anti-TNF agents may be an attractive option).2052 Figure 1. 20 x10 x 2cm non-healing ulcer on the left medial calf, with elevated violaceous borders.

Orbital Adnexal Lymphoma Diagnostic Misalignment

Lymphomas are known as neoplasm’s caused by clone proliferation of B and T lymphocytes. Extranodal lymphoma arises from tissues other than lymph nodes or even from sites which normally doesn’t contain lymph tissues. Orbital adnexal lymphoma arises from eyelid, orbit, lacrimal glands or conjunctivae and it is totally different from intraocular lymphoma. Wide range of differential diagnosis including infectious inflammatory orbital disease, preseptal and orbital cellulitis, orbital idiopathic inflammatory disease-pseudotumors, especially dacryoadenitis and myositis and thyroid associate orbit disease makes the diagnosis of orbital adnexal lymphoma even more difficult. We represent the case of diagnostic delay of very aggressive form orbital non-Hodgkin lymphoma occurred because of the unspecific signs and symptoms as well as not indicative imaging investigation and laboratory tests.

A rash diagnosis: Gemcitabine-associated pseudocellulitis.

Gemcitabine is an antitumor agent with broad clinical application. The most common cutaneous toxicities are mild rash and pruritus; however, a severe 'pseudocellulitis' rash, which resembles infectious cellulitis in clinical presentation, has increasingly been recognized as a rare complication of this agent. Though the specific pathophysiology related to this condition is not clear, it has been observed to occur primarily in regions of significant lymphadenopathy or prior radiation exposure typically after 24-48 h following administration of gemcitabine. It is a self-limiting reaction, with most cases resolving within two to seven days of onset without any specific treatment for the rash. Treatment with gemcitabine may be safely continued in patients with this complication, though recurrence of the rash is common following repeated doses. We report a case of biopsy confirmed gemcitabine associated pseudocellulitis in a patient treated for metastatic pancreatic adenocarcinoma. Knowledge of this complication is important to avoid unwarranted hospitalizations and antibiotic use in patients treated with gemcitabine.

Clinical efficacy of rituximab in the treatment of pemphigus: A retrospective study.

Pulsed corticosteroids have been used successfully for the management of pemphigus. However, prolonged use of glucocorticoids may be associated with adverse effects and some patients show a poor response to conventional therapy. Biologics have shown a promising role in such cases; however, there is limited data from the Indian subcontinent. The primary objective was to assess the efficacy and adverse effects of rituximab in pemphigus. The secondary objective was to measure the cumulative doses of corticosteroids required for these patients. We undertook a retrospective review of records of 25 pemphigus patients (pemphigus vulgaris: 21, pemphigus foliaceus: 4) who had received rituximab infusion (rheumatoid arthritis protocol in 21 patients, modified in 4). Oral prednisolone was administered in dosages up to 0.5 mg/kg of body weight and tapered over the next 3-4 months according to the disease activity. However, other immunosuppressive agents such as cyclophosphamide and azathioprine were continued for one year after clinical remission was achieved. Complete remission was observed in 22 (88%) patients. The mean time to disease control and complete remission was 1.10 and 4.36 months, respectively. Four (16%) patients experienced relapse after a mean duration of 11.75 months. The mean total dose of oral steroids administered was equivalent to 3535.64 mg of prednisolone. Exacerbation of disease was noted in two patients after the first dose of rituximab and infectious complications, pneumonia and cellulitis, developed in one patient each. A small sample size, the retrospective nature of the study and unavailability of follow-up anti-desmoglein autoantibodies levels were limitations. Rituximab is an effective agent in the treatment of pemphigus. The use of rituximab enabled use of a lower initial dose of oral prednisolone in pemphigus and hence reduced its total cumulative dose. Severe side effects were rare.

Local Allergic Reaction to Ocular Chloramphenicol Ointment: A Diagnosis by High Index of Clinical Suspicion

Chloramphenicol is a widely used topical ointment applied routinely for ocular and periorbital infections due to its wide spectrum of anti-bacterial activity. Local delayed hypersensitivity reaction to chloramphenicol is a well reported but uncommon adverse effect, and has been reported to mismanaged initially as an infective cellulitis. The confirmatory tests for drug allergy are often not possible in developing countries and hence, the diagnosis is usually made with high index of clinical suspicion. Hereby, we are reporting a case of local hypersensitivity reaction to chloramphenicol after ocular use for adenexal infection, which was diagnosed with high index of suspicion without any diagnostic test, and was managed timely and successfully.

Allergie aux piqûres de moustiques

Althought serious illnesses can be transmitted by mosquitoes, the most frequent manifestations are due to the contact with saliva of mosquitoes during the blood meal. Culex and Aedes are meeting in countries with moderate climates. Clinical signs vary according to the immunoallergical response, from simple pruritic wheals to immediate and/or delayed allergic reactions. Some reactions can provoke confusion with an infectious cellulitis and an inappropriate antibiotherapy. The natural history of insect bite reactions in an individual tends to progress through 5 stages until immunizing tolerance settles down. Skin prick testing or Serum specific IgE of whole body extracts are lacking sensibility and specificity. Actually, they must be reserved for the most invalidating or severe cases. The recombinant allergens of the saliva of mosquitoes should allow to improve diagnosis and to envisage immunotherapy.