Left Antecubital Fossa Research Articles

Early-Life Skin Microbial Biomarkers for Eczema Phenotypes in Chinese Toddlers.

Eczema is a common inflammatory skin disorder during infancy. Evidence has shown that skin-microbiome fluctuations may precede eczema development, but their predictive value for eczema phenotypes remains unknown. We aimed to investigate the early-life evolution of the skin microbiome and its temporal associations with different pairs of eczema phenotypes (transient versus persistent, atopic versus non-atopic) in Chinese children. We followed 119 term Chinese infants from birth to 24 months old within a Hong Kong birth cohort. The skin microbes at the left antecubital fossa were serially sampled by flocked swabs at 1, 6, and 12 months for bacterial 16S rRNA gene sequencing. The atopic sensitization at 12 months was strongly associated with eczema persisting to 24 months (odds ratio 4.95, 95% confidence interval 1.29-19.01). Compared with those with non-atopic eczema, the children with atopic eczema had reduced alpha diversity at 12 months (p < 0.001) and transiently higher abundance of the genus Janibacter at 6 months (p < 0.001). Our findings suggest that atopic sensitization at 12 months may predict persistent eczema by 24 months, and atopic eczema at 12 months is associated with unique skin microbiome profiles at 6 and 12 months. Non-invasive skin-microbiome profiling may have predictive value for atopic eczema.

Congenital absence of the skin: a case series report

BackgroundExtracranial congenital skin defects, defined as aplasia cutis congenita (ACC), are a rare clinical entity. The form of presentation varies among patients according to the causal agent and the point during pregnancy at which the defect occurs. We present a series of cases of noncranial ACC, analysing its possible etiopathogenesis and the evolution of the lesions.Materials and methodsThis is a retrospective review of cases of extracranial ACC at a tertiary hospital.Case presentationPatient 1 is a full-term newborn of a monochorionic diamniotic gestation with the death of one foetus at 14 weeks of gestational age. Physical examination revealed two skin defects located on the posterior aspect of both thoraco-abdominal flanks. Patient 2 is a full-term newborn presenting with an ulcer on the nasal tip and cephalic extension on a follow-up pregnancy ultrasound. Patient 3 is a full-term newborn of a monochorionic diamniotic gestation with twin feticide due to encephalocele, presenting an ulcer on the lateral aspect of the proximal third of her right leg. The gestation associates severe oligohydramnios due to premature rupture of the membranes and breech presentation. Patient 4 is a full-term newborn with an ulcer on the left antecubital fossa with no relevant gestational history.ConclusionThe analysis of the obstetric history and the clinical presentation of the lesions helps to guide the aetiopathogenic diagnosis of congenital skin defects. The increased intracompartment pressure in the limbs is related to the increased severity of skin lesions and musculoskeletal and nerve involvement. Conservative treatment is related to a good prognosis for the lesions.

Sodium-ypochlorite injection in antecubital fossa: A case report and literature review.

IntroductionCaustic cutaneous injections are rare and may result in challenging soft tissue defects necessitating urgent surgical reconstruction to preserve vital structures.We report a unique case of self-inflicted sodium hypochlorite injection to the left antecubital fossa as a suicidal attempt, which resulted in an exposed median nerve and brachial artery. The adventitia of the brachial artery was injured in this case; hence, the risk of an arterial blowout was considerable.After thorough debridement, the defect was reconstructed successfully with a reverse lateral arm flap.ConclusionHousehold bleach (sodium hypochlorite) injections are rare and may result in challenging soft tissue defects necessitating urgent surgical reconstruction to preserve vital structures.

Dermatologic ultrasound in the management of childhood linear morphea

Linear morphea is the most common subtype of localized scleroderma in the pediatric population. This condition can be quite disabling, with complications such as growth defects and painful flexion contractures. Assessment of disease progression and early intervention are key to minimize morbidity. We report linear morphea in a previously healthy 12-year-old girl. The patient presented with a one-year history of a linear plaque crossing her left antecubital fossa, measuring 7x3cm. The diagnosis was confirmed by biopsy, in which deep tissue involvement was noted. Subsequent management and evaluation of the disease activity was done by ultrasound, which allowed precise guidance of pharmacotherapy. The patient improved both clinically and sonographically with a methotrexate course. Sonographic changes accurately described the disease activity on follow up assessments. Features suggestive of an active phase include a thickened and hypoechoic dermis contrasting hyperechoic subcutaneous tissue. The atrophic stage is characterized by a thinned-out dermis and subcutaneous area. Typical vascular traits of each disease phase can also contribute to the assessment. Ultrasound is a grossly underused tool in the field of dermatology. It can provide accurate and sensitive information about disease activity in linear morphea, allowing for more timely intervention and optimal patient management.

26414 An uncommon presentation of Sweet syndrome

Sweet syndrome (SS) is a neutrophilic dermatosis characterized by an abrupt onset of painful erythematous skin lesions in association to fever, leukocytosis and occasionally, pathergy. Giant cellulitis-like SS is a rare variant characterized by large painful erythematous plaques resembling cellulitis. A 42-year-old female with acute myeloid leukemia (AML) presented with fever and two erythematous tender plaques localized to the left antecubital fossa and the left proximal medial thigh. Histopathologic evaluation of a biopsy from the left thigh lesion demonstrated findings suggestive of erythema nodosum.

Comparing the Potential for Irritation of a Ceramide-Based Moisturizer with a Urea-Based Moisturizer for Pediatric Atopic Dermatitis.

IntroductionMoisturizers are one of the mainstays of the topical treatment of atopic dermatitis (AD). One of the adverse effects of moisturizers is skin irritation, especially on excoriated AD skin. We compared the potential for irritation of two commercially available moisturizer products for the treatment of AD: a ceramide-based moisturizer (Ceradan® Cream; Hyphens Pharma Pte Ltd, Singapore) and a urea 5% moisturizer (Aqurea Lite Cream; ICA Pharma Pte Ltd, Singapore).MethodsWe performed a prospective single-blind randomized controlled study recruiting AD patients aged between 8 and 16 years with symmetrical or near symmetrical scratch marks (excoriations) of at least grade 2 to 3 severity score, according to the Eczema Area and Severity Index (EASI), over bilateral antecubital fossae. Subjects were randomized to receive the ceramide-based moisturizer to either the left or right antecubital fossa or urea 5% cream to the other antecubital fossa. Subjects were asked to grade the immediate skin irritation of both creams on a standard visual analogue scale (VAS) and which cream they would prefer to use as a daily moisturizer. Primary outcome was the mean irritant score of each cream, and secondary outcome was the subjects’ preference of either cream as their daily moisturizer.ResultsA total of 42 participants were enrolled with a mean age of 11 years 5 months. The ceramide-based cream had a significantly lower mean VAS score (mean 0.69, SD = 1.63) for irritation compared with urea 5% cream (1.43, SD = 1.64) (p = 0.035). More participants also preferred the ceramide-based cream over urea 5% cream (62% versus 38%) as their daily moisturizer, but this did not reach statistical significance (p = 0.164).ConclusionsA ceramide-based moisturizer may be considered as a suitable choice for children to minimize irritation from moisturizer treatment for AD.

2077 A Rare Case of Migratory Urticaria Causing Dysphagia During an Acute Flare of Ulcerative Colitis

INTRODUCTION: Ulcerative colitis (UC) is characterized by chronic mucosal inflammation limited to the colon. The most common manifestation of UC is progressively worsening hematochezia that may be accompanied by extraintestinal manifestations including, peripheral arthritis, uveitis, primary sclerosing cholangitis, fatty liver, venous/arterial thromboembolism, and pulmonary disease. Erythema nodosum (EN) and pyoderma gangrenosum (PG) are the most common dermatologic manifestations. Uncommonly, UC may present with unpredictable urticaria and angioedema that may be life threatening. We present a rare care of acute UC flare with migratory urticaria as the initial presenting symptom. CASE DESCRIPTION/METHODS: A 25-year-old woman with UC presented with 1 week of abdominal pain, bloody stools, bilateral ankle and knee pain with non-blanching rash over her right shoulder, left armpit, and left groin. GI PCR and C. difficile assay were negative. Rheumatoid factor, double stranded DNA, anti-cyclic citrullinated peptide antibodies, anti-Smith antibody, anti-ribonuclear protein, and C1 esterase inhibitor were negative. The patient was started on cetirizine with resolution of the arthralgia. However, new rashes were noted under right axilla and left antecubital fossa over a two day period. Patient subsequently developed dysphagia and left sided mandibular swelling. Indirect laryngoscopy was unremarkable. She was immediately treated with IV methylprednisolone and transitioned to a slow oral steroid taper over 3 months with improvement of gastrointestinal and dermatologic symptoms. Skin biopsies revealed superficial and mid-dermal perivascular lymphocytic infiltrate consistent with urticaria. DISCUSSION: This patient presented with unpredictable migratory skin lesions involving multiple mucosal surfaces that brought concerns of possible airway involvement. The etiology was initially unclear as limited infectious and rheumatologic work up was negative, as well as negative allergen and medication exposure. Cutaneous vasculitis was considered, however biopsy showed urticaria. Patient’s symptoms significantly improved after the initiation of oral steroids. Migratory urticaria with associated angioedema can be a manifestation of an acute flare of UC that warrants evaluation by otolaryngologist and prompt initiation of steroids. Glucocorticoids may address symptoms of a pro-inflammatory state while allowing for more time to rule out other etiologies of extraintestinal manifestations of a patient’s presentations.

Bacteraemia Following Different Orthodontic Treatment Procedures

The purpose of this research was to estimate the percentage and nature of bacteraemia following four orthodontic treatment procedures which were: an upper alginate impression, separator placement, band fitting or placement, and arch wire adjustment on a fixed appliance. The study group consisted of 40 patients (25 females and 15 males) ranging from 17-25 years of age attending Orthodontic Department in the College of Dentistry/Baghdad University, and out patients department from private clinic. The 40 patients were divided into four groups (10 patients each). A cannula was inserted into either the left or right antecubital fossa using an aseptic technique. A 5ml of blood was taken immediately before orthodontic treatment procedure and a second 5ml sample was taken 1-2 minutes after the procedure.The blood samples showed a percentage of bacteraemia of 50%, 40%, 30%, and 20% in cases of post-band placement, post-separator placement, post-arch wire adjustment, and post-alginate impression procedures respectively.This investigation demonstrated that the placement of separator and fitting of band procedures could cause a significant bacteraemia, thus these procedures for patients at–risk of bacterial endocarditis should be placed in consideration, and the orthodontist should be advised to consult the patient's medical specialist for controlling and prescribing the necessarily antibiotic coverage.

Brachial artery repair using the basilic vein as a reliable conduit in a 3-year-old child

A supracondylar fracture of the humerus is the most common upper extremity fracture in children with concurrent neurovascular complications. However, bypass grafting in the management of a pediatric open elbow dislocation with an arterial injury has rarely been reported in the literature. Hence, an adequate conduit for a vessel graft interposition remains questionable when a primary anastomosis is limited in an arterial reconstruction. The purpose of this study is to present a brachial artery reconstruction in a 3-year-old patient with an open supracondylar fracture of the humerus. In the clinical and surgical examination of the patient, an open wound in the left antecubital fossa presented with accompanying brachial artery injury. To repair the artery, a reverse end-to-end anastomosis was conducted using basilic vein graft from the ipsilateral arm under general anesthesia. The patient had palpable radial pulses in the postoperative clinical examination and was discharged without complications. The great saphenous vein (GSV) has proven to be the most common and the best conduit for arterial reconstruction of the upper extremity in the adult patients. However, the GSV graft is known to have the propensity for becoming aneurysmal in pediatric patients. Some studies have demonstrated the basilic vein as a suitable conduit in pediatric patients, in that it has durable patency, fewer branches, size compatibility for anastomosis, and proximity to the brachial artery. Our case confirms the safety of using this autogenous vein from within the zone of injury for arterial reconstruction, after a supracondylar humeral fracture. The management of pediatric elbow fractures accompanying vascular injuries can be technically demanding due to relatively small, delicate structures and concurrent neurovascular network. Nonetheless, a vascular injury should be treated with high level of suspicion and immediate intervention to avoid any limb ischemia or loss. In situations where the brachial artery is compromised and needs repair with a bypass, the basilic vein should be considered as a conduit for its greater accessibility and long-term patency.

Topical ethyl chloride to reduce pain associated with venous catheterization: a randomized crossover trial

ObjectiveTo compare pain associated with venous catheterization after administration of topical ethyl chloride vs placebo among emergency department health care providers. MethodsWe conducted a randomized, double-blind, placebo-controlled, crossover trial among a convenience sample of health care provider volunteers in a tertiary care urban emergency department. We randomly allocated subjects to initial treatment (ethyl chloride vs sterile water aerosol spray) and catheterization site (left or right antecubital fossa). After venous catheterization placement and discontinuation, subjects underwent a 5-minute washout period. All subjects then underwent venous catheterization in the contralateral antecubital fossa after administration of the alternative agent. We measured all outcomes after discontinuation of the second catheter. The primary outcome was difference in pain verbal numeric rating scale score (0-10) between the 2 agents. Secondary outcomes included preferred agent (binary) and future willingness to use agent on patients (5-point Likert scale). ResultsThirty-eight health care providers were recruited; all completed the study. Median pain verbal numeric rating scale scores were 4 (interquartile range, 2-5) for placebo vs 2 (1-4) for ethyl chloride. The effect size for pain reduction with ethyl chloride compared with placebo was 2 (95% confidence interval, 0.5-2; P = .001). Most subjects (68.4%) preferred ethyl chloride to placebo. Five-point Likert scale scores measuring willingness to use preferred product on future patients were higher by 2 (95% confidence interval, 1-3) among subjects preferring ethyl chloride vs placebo. ConclusionsWe found that topical ethyl chloride yields a greater reduction in pain associated with venous catheterization compared with topical placebo.

Investigation of bacteremia after separator placement

Background: Simple orthodontic procedure such as separator placement can be associated with the occurrence of transient bacteraemia. Use of clorhexidine before separator placement has been recommended as a measure to decrease the bacteraemia. Aim: The purpose of this study was to detect the presence of transient bacteremia after separator placement following use of 0.2% chlorhexidine gluconate mouthwash. Methodology: The study group consisted of 27 adult patients who reported for orthodontic treatment (18 males and 9 females). The patients were asked to rinse their mouth for 60 sec with 15 mL of 0.2% chlorhexidine gluconate mouthwash before the separator placement. An aseptic technique was used to draw out 5 ml of blood was from either the left or right antecubital fossa immediately before orthodontic separator placement (as control group), and the second 5 ml sample was taken 1–2 min after the placement of separators mesial and distal to all the first molars. All the blood samples were inoculated into culture bottles containing Brain Heart Infusion and incubated aerobically for 7 days. Media used for bacterial growth is chocolate agar and MacConkey agar. Results: From a total of 27 patients and 54 samples, none of the sample was found positive for bacteremia. Conclusion: This study demonstrated that there is no bacteremia after the placement of separators following the use of chlorhexidine mouthwash.

Tissue necrosis after propofol extravasation

Dear Editor, We describe a case of an adverse event in which significant tissue necrosis resulted in a 56-year-old male after extravasation of propofol following elective vascular repair for bilateral iliac aneurysms. The patient’s past medical history was significant for peripheral vascular disease, diabetes mellitus, and ischemic heart disease. His postoperative course was problematic, requiring multiple surgeries for complications. On postoperative day 10 of his stay in the intensive care unit (ICU) he remained intubated and sedated, and propofol (10 mg/mL in 10 % lipid solution; AstraZeneca, Ontario, Canada) was infused interstitially in the left antecubital fossa site. It had been running alone through this dedicated line, and it was unknown how much volume was involved. The area which ultimately sloughed skin was found to be indurated. The infusion was stopped and the area treated conservatively. Over the next few days, the patient developed left arm cellulitis, skin sloughing, and purulence in a 5.1 9 5.1-cm area around the site. Initially, the area of necrosis seemed to be 5 9 3.5 cm. Daily washing, saline dressings, and Intracyte gel with Telfa were used on the wound. During his stay, the patient developed an elevated white blood cell count and temperature. Broad-spectrum antibiotic coverage was initiated after consultation with the infectious diseases service. Deep tissue cultures revealed coagulase-negative Staphylococcus with scant yeast, subsequently growing Candida albicans. One week after the incident, the necrotic fat and fascia overlying the biceps as well as thrombosed portions of the basilic and cephalic veins were debrided (Fig. 1). The wound was irrigated with a betadine-containing solution and packed open. Eventually, a vacuum-assisted closure device was put in place, and subsequent assessments indicated the base of the wound appeared to be healthy. The wound continued to improve, and on postoperative day 71, the wound was approximated with a Steri-Strip creep method, where the normal skin was pinched together and Steri-Strips applied to the edge. On post-operative day 119, the area had completely healed, and the patient was discharged home 7 days later. There are few documented incidences of extravasations of propofol resulting in injury producing tissue necrosis [1–4]. The effects of the infusion were seen quite quickly (within 2 days). In one case report, the deconditioned nature of the patient secondary to undernutrition and septic shock were thought to contribute to the necrosis induced by propofol [3]. Our patient had peripheral vascular disease and diabetes, which may have predisposed him to injury and delayed healing. To contain the amount of damage some authors recommend attempting aspiration of the fluid before needle withdrawal, as well as using Ringer’s solution or saline as a ‘‘flush-out’’ within 24 h of the injury [2, 4, 5]. This requires a proximal incision to the area where a cannula is inserted into the subcutaneous space. The solution is then infiltrated and allowed to drain. Depending on the extent of the injury, debridement may be necessary. Considering the frequency of the use of propofol in the ICU setting, this report highlights the need for careful monitoring of intravenous lines containing propofol.

Global Hepatic Uptake of (99m)Tc-MAA During VQ Scintigraphy Secondary to Synchronous Superior and Inferior Vena Caval Obstruction: a Demonstration of Trans-Portal Venous Collateral Pathways.

A 38-year-old woman underwent lung scintigraphy. Injection of technetium-99m macroaggregated albumin (99mTc-MAA) via the left antecubital fossa revealed global hepatic uptake (Fig. 1). Review of contemporary computed tomography (CT) imaging demonstrated synchronous superior and inferior vena cava (SVC and IVC) obstruction, with formation of systemic-portal venous collateral pathways (Fig. 2). Systemic-portal venous collateralisation can in rare circumstances lead to focal hepatic uptake of 99mTc-MAA during lung scintigraphy. This case of global hepatic uptake, secondary to synchronous SVC and IVC obstruction, demonstrates the trans-portal venous collateral pathways leading to this unusual imaging outcome (Fig. 3). Fig. 1 A 38-year-old woman, at risk of venous thromboembolic disease secondary to Factor V Leiden disorder, was referred for lung scintigraphy (a, ventilation scan posterior view). Perfusion scanning (b, left posterior oblique view) revealed global hepatic uptake ... Fig. 2 Three-dimensional CT reconstruction demonstrating left-sided systemic-portal collateral venous pathways (arrowheads retroperitoneal venous collaterals, white arrow dilated inferior mesenteric vein, black arrow haemorrhoidal plexus). Review of contemporary ... Fig. 3 Diagram of proposed systemic-portal venous collateral pathways. The first pathway involves two grossly dilated retroperitoneal veins which ascend to anastomose with a left renal/splenic venous confluence (more commonly recognised in hepatofugal flow in ...

Relationship between odontogenic bacteremia and orthodontic stripping

The aim of this study was to evaluate the prevalence of bacteremia associated with an orthodontic stripping procedure. The study included 29 orthodontic patients (mean age, 18.2 ± 3.4 years). We used a standardized stripping procedure: a perforated stripping disk with a contra-angle hand piece was used at a low speed (<15,000 rpm; 10 seconds) on the mandibular anterior teeth. Blood samples were collected by inserting a cannula into the left antecubital fossa. A baseline sample was taken before treatment, and a second sample was taken after the stripping procedure. These samples were inoculated into aerobic and anaerobic blood culture bottles and incubated, and the bacterial cultures were identified; the samples collected before and after the stripping procedure were statistically analyzed. Transient bacteremia was not detected in any pretreatment blood sample, but it was found in 1 postoperative blood sample; this sample tested positive for Streptococcussanguis. The bacterial species in the positive postoperative blood sample was S sanguis, which might be associated with infective endocarditis. Clinicians should explain the level of risk to the patient and consult a concerned medical specialist.

FDG Injection Site Extravasation

18F-FDG PET/CT plays an important role in the management of non-small-cell lung cancers (NSCLC). The treatment options for NSCLC depend upon the initial staging of the disease. The authors report a case with a potential pitfall of overlooking a site of FDG uptake as radiopharmaceutical extravasation at an injection site. The PET/CT demonstrated a T2a N2 bronchial carcinoma, with a solitary focus of FDG uptake at the left antecubital fossa where FDG was administered. Careful interpretation of the images reveals a solitary skeletal metastasis in the left proximal ulna, which makes the disease stage IV rather than IIIA, leading to a significant difference in treatment.

An unusual skin lesion derived from postmortem ecchymoses in a donor skin graft site

A 42-year-old female patient was found dead hanging in a shower room in a psychiatric hospital. The woman had suffered from a persecutory type of paranoid disorder over a long period. Six weeks prior to death, she attempted suicide by injecting gasoline into the cubital vein of her left arm. Clinical records showed that a skin graft, which was taken from the left femoral region, was transplanted to the left antecubital fossa, replacing the necrotic skin adjacent to the site where the gasoline was injected. According to the inquest records and police investigations, the body had been suspended for at least 7 h before it was discovered. Medico-legal autopsy, which was commenced 2.5 days after death, revealed early putrification of the corpse, which measured 161 cm and weighed 71.5 kg. Non-blanchable livor mortis with numerous postmortem ecchymoses involved most of the skin of the legs. The external examination of the body showed signs of her previous medical treatment, which was performed in the hospital when she had injected gasoline, in the form of a linear scar (29 cm in length) on the anterior side of the left upper to forearm and a triangular scar (5 9 4.5 cm) in the left antecubital fossa. Autopsy revealed the cause of death to be hanging, which was evidenced by the following findings: ligature mark measuring 1.5 cm in width around the neck; hemorrhage at the periosteal origin of the right sternocleidomastoid muscle; fracture of the left upper horn of the thyroid cartilage; hemorrhages under the anterior longitudinal ligament of the lumbar vertebral column (‘‘Simon’s bleedings’’). However, the most notable finding was a rectangular (8 9 4 cm) dark purple, bruise-like skin lesion surrounded by dense postmortem ecchymoses on the anterior side of the left thigh (Fig. 1). Histopathology of this lesion showed subepidermal blistering and interstitial extravasation of erythrocytes in the dermis, but without any surrounding inflammatory cellular response or thrombosis (Fig. 2).

Gas-Producing Cellulitis from Injection of Spot Remover Fluid (n-Hexane)

BackgroundSubcutaneous administration of hydrocarbons, categorized according to their toxicological profiles, is rare compared to oral, inhalational, and cutaneous routes of exposure. Furthermore, injection of n-hexane in humans has not been described. ObjectivesThis report demonstrates a singular case of subcutaneous administration of n-hexane. Case ReportA 21-year-old man presented to the Emergency Department (ED) 7 h after injecting his left antecubital fossa with approximately 5 cc of spot remover fluid, which contained more than 95% n-hexane, in a suicide attempt. There was redness in the left forearm, but no apparent swelling was observed. He was administered tetanus prophylaxis and discharged with follow-up. However, the patient returned to the ED 14 h later, complaining of progression of the swelling around the injection site extending to the axilla. Significant volume of air in the soft tissue of the affected extremity was noted on both the radiograph and computed tomography scan; therefore, an immediate extensive incision and debridement of the diseased limb was performed. The postoperative course was uneventful, and a complete resolution of emphysema without any functional deficits was obtained for 5 months of follow-up. ConclusionIn patients suffering from n-hexane injection, initial physical examination findings may not be apparent. Thus, the patient must be monitored closely for evidence of a spread of subcutaneous gas with elevation and immobilization. If increase in tissue pressure or spread of gas is not prevented, as in our case, immediate incision and removal of the toxic substances should be planned.

The First Description of Docetaxel-Induced Recall Inflammatory Skin Reaction after Previous Drug Extravasation

To describe a cutaneous recall soft tissue injury at the site of previous extravasation of docetaxel. A 65-year-old white female with an invasive ductal carcinoma of the right breast was treated with carboplatin AUC 2 and docetaxel 30 mg/m(2) weekly via a peripheral vein access. During the 14th cycle, drug extravasation of docetaxel occurred in the left antecubital fossa characterized by a mild erythema without edema. A severe erythema developed in the former area of extravasation after the 15th cycle of carboplatin/docetaxel. The recall dermatitis continued to exacerbate after each course of systemic docetaxel chemotherapy and finally led to termination of this therapy. In general, extravasation of docetaxel causes only mild local skin reactions without further necessity of intervention. For pegylated liposomal doxorubicin and paclitaxel, inflammatory recall phenomena at sites of previous drug extravasation are rare and often occur as single events following administration of the same cytotoxic drug. According to the Naranjo probability scale, the administration of docetaxel in this case probably led to the cutaneous soft tissue injury as a result of extravasation. Caution is needed after an episode of docetaxel extravasation. Even after a therapy interruption of several weeks, resumption of chemotherapy with docetaxel might lead to recrudescence of the inflammatory skin reaction.

Fungal Infection from Sweeping in the Wrong Place

A 43-year-old man presented with fever, malaise, a nonproductive cough, and skin lesions near the left eyelid and eyebrow (Panel A) and left antecubital fossa (Panel B). The symptoms had developed during the course of several weeks. The patient underwent a biopsy of the facial lesion. Histopathological analysis of the biopsy specimen revealed changes characteristic of coccidioidal infection, including granulomatous inflammation and spherules containing endospores (Panel C, arrow; hematoxylin and eosin). Antibodies to coccidioides species were present in his serum. Although the patient had no history of travel to an area where coccidioidomycosis is endemic, he worked as a driver . . .

Prevalence of Staphylococcus aureus and antibiotic resistance in children with atopic dermatitis: A New Zealand experience

Children with atopic dermatitis often have infective exacerbations which are treated with antibiotics and/or antiseptics. The most common infective cause is Staphylococcus aureus with a worldwide trend towards antibiotic resistance. This prospective observational audit aimed primarily to establish the prevalence of S. aureus colonisation in New Zealand children with atopic dermatitis attending a specialised paediatric dermatology clinic. Secondary aims were to assess whether S. aureus colonisation correlated to clinical severity, the sensitivity patterns to antibiotics (in particular methicillin-resistant S. aureus, and to identify any demographic or management risk factors. Subjects were children aged 18 years or younger attending a tertiary public hospital dermatology clinic with a diagnosis of atopic dermatitis. Demographic and social data, as well as current and previous systemic and topical treatments, were recorded. Patients were examined and the extent of atopic dermatitis determined using a standardised scale (Scoring Atopic Dermatitis (SCORAD)). Two skin swabs were taken for culture and standard sensitivities; one from the left antecubital fossa and one from the worst area of atopic dermatitis. Microbiological cultures and density of S. aureus colonisation were recorded. SCORAD and density of S. aureus culture were correlated. Demographic and clinical data from children with S. aureus was analysed. One hundred children were recruited from March 2007 to May 2008. S. aureus was isolated from 68 patients. There was a positive correlation between the density of S. aureus culture and severity of SCORAD (Spearman r = 0.55, P < 0.0001). There was also a positive, though weaker, correlation between SCORAD and ethnicity with Māori /Polynesian children generally having more severe atopic dermatitis (r = 0.22, P = 0.028). Although a greater proportion of Māori or Pacific Island children were colonised by S. aureus than other ethnic groups this did not reach statistical significance (78% and 60%, respectively, P = 0.0842). There was no significant correlation between either S. aureus prevalence or its density and age (r = 0.09, P = 0.39 and r = 0.12, P = 0.23, respectively). There were no significant differences in sex or treatments (use of antibiotics, antiseptics, calcineurin inhibitors, emollients or corticosteroids) between S. aureus-positive and S. aureus-negative children. Only 12 S. aureus-positive children demonstrated antibiotic resistance, 10 to erythromycin and only two to flucloxacillin. Three quarters of children with atopic dermatitis have at least one positive culture, of which the vast majority is S. aureus. The density of S. aureus colonisation correlates to severity of atopic dermatitis. Children who are S. aureus culture-positive had no significant demographic or clinical features different to children who were culture-negative. Only two children grew S. aureus resistant to flucloxacillin (2% resistance rate), which remains the ideal first line of treatment in our local population.