Leg Cellulitis Research Articles

Lower leg cellulitis: A guide to diagnosis and management

Linda Nazarko looks at what nurses need to know about this commonly misdiagnosed condition

Musculoskeletal melioidosis in a 33-year-old farmer presenting with the right leg cellulitis: A case report from North India

Melioidosis, caused by Burkholderia pseudomallei, has been described as “the great mimicker” due to its varied clinical presentation. Musculoskeletal melioidosis is a rare presentation of this disease, and here we report a 33-year-old male, farmer from Madhya Pradesh, who presented with fever for 2 months and right leg swelling for 25 days. He was treated elsewhere as cellulitis and managed with intravenous antibiotics and fasciotomy. Magnetic resonance imaging knee and leg showed diffuse osteomyelitis of the upper tibia with similar tiny foci and sinus tract present. A diagnosis of the right knee septic arthritis with multifocal osteomyelitis was made. Focal pus culture grew pansensitive B. pseudomallei. He was started on Inj. Meropenem and oral cotrimoxazole tablet. He also underwent right tibial debridement, sequestrectomy, and saucerisation. He was discharged after initial therapy and has improved significantly on follow-up. This case highlights a very common clinical condition caused by a rather uncommon etiological agent and therefore renumerates the importance of insightful clinical suspicion with appropriate use of investigations and treatment options to prevent further morbidity and mortality.

Unusual Presentation of Rhabdomyolysis & Acute Kidney Injury in a Young Patient with Associated Pancreatitis of Un-Known Etiology

A case of 41-year-old patient presented with left lower leg cellulitis, laboratory investigations showed elevated CK levels of more than 193000 U/L, high pancreatic enzymes level namely amylase & lipase, significant electrolyte and acid base abnormalities. Diagnosis of Rhabdomyolysis made based on CK level results in acute pancreatitis. This patient developed acute renal failure with all above in mind, he stayed inpatient for 19 days. The purpose of this case report is to highlight the unusually high CK with unusual association of acute pancreatitis leading to rhabdo¬myolysis and the associated morbidity.

Analysis of hospitalizations of patients with Kaposi sarcoma: A national population-based study.

e18821 Background: Kaposi sarcoma (KS) is a type of soft tissue sarcoma due to infection with human herpes virus 8 (HHV-8) and can be associated with acquired immunodeficiency syndrome [AIDS]. Recent national population data are scarce on reasons for hospitalizations, epidemiology, and hospitalization outcomes of patients with KS in the United States (U.S). Methods: Data were abstracted from the National Inpatient Sample (NIS) Database. This database is the largest collection of inpatient admission data in the U.S. It is a 20-percent stratified sample of all discharges from U.S. community hospitals, excluding rehabilitation and long-term acute care hospitals. The numbers in the databases are weighted to optimize national estimates. Hospitalizations for patients with KS were obtained by searching for hospitalizations that contained ICD-10 code “C46” as a principal or secondary diagnosis. The principal diagnosis is the main reason for the admission, while any other diagnosis other than the principal, are secondary diagnosis. The reason for hospitalization (or principal diagnosis) was recorded in descending order of frequency based on the ICD-10 code organ system category and specific principal diagnosis. The total number of KS discharges, baseline demographic characteristics, hospital length of stay (LOS), and total hospital charges were recorded. STATA 16 was used for analysis. Since NIS contains de-identified data, Institutional Review Board (IRB) review was waived. Results: There were 32 million discharges included in the 2020 NIS database. Of those, 2,785 hospitalizations were for patients aged ≥18 years, who had either a principal or secondary ICD 10 code for KS. Patients were mainly males (91%), black (40%), mean age of 48 years, inpatient mortality of 9.3%, mean LOS of 9 days, and mean total hospital charge of 132,476 U.S dollars. The 5 most common reasons for hospitalization by ICD 10 code categories were infections (52.4%), cardiovascular (6.5%), respiratory (6.1%), neoplasm and hematologic (5.6%), and skin (5.6%). The 5 most common specific principal diagnoses for hospitalizations were Human immunodeficiency virus [HIV] disease (29.1%), sepsis (12.7%), left leg cellulitis (2.7%), pneumonia (2.2%), and Acute kidney injury (1.8%). Conclusions: Hospitalizations for KS patients are mostly black middle-aged men, with high inpatient mortality, long LOS, and significant hospital charges. Infections and HIV were the most common reasons for hospitalizations. Management of underlying HIV and measures for prevention, early detection, and prompt treatment of infections in the outpatient setting are important in preventing hospitalizations of these patients.

PS-R03-10: CASE REPORT: CUSHING SYNDROME IN A YOUNG MALE

A 27-year-old male without any significant past medical history was advised to visit a hospital for elevated blood pressure, elevated liver enzymes, and dyslipidemia in a workplace health checkup. His body weight had increased by more than 10 kg in the last two years. He presented to our department and underwent laboratory work-up. He had bilateral lower limb pitting edema, hypokalemia, and elevation of low-density lipoprotein. No sign of dysthyroidism, renin-angiotensin-aldosterone system disorder, or increased catecholamine secretion was found. Diet and exercise therapy and calcium channel blocker did not improve his hypertension, and he suffered from lumber vertebral fracture, refractory hypokalemia, and lower leg cellulitis. He was admitted to our department for detailed examination of worsening lower limb edema. On admission, he had striae on his abdomen and legs as well as edema of both lower extremities. The endocrinological data showed high levels of adrenocorticotropic hormone (ACTH) and cortisol. Overnight 1 mg dexamethasone suppression test resulted in a non-suppression response, and his circadian rhythm of cortisol was absent. Urine cortisol level was high. These findings confirmed the diagnosis of ACTH-dependent Cushing syndrome. A contrasted magnetic resonance imaging (MRI) scan demonstrated enlargement of the pituitary gland more than 1 cm in length. Taking into account drug-resistant hypokalemia and vulnerability to infection, he was administered with metyrapone 500 mg per day until he underwent transsphenoidal hypophysectomy. The pathological findings were consistent with that of a pituitary adenoma. Postoperative MRI scan showed remnant lesions which stretch to the bilateral cavernous sinuses and the right middle cranial fossa. Although a decrease in urine cortisol was observed, the absence of a circadian rhythm of cortisol, hypertension, and hypokalemia persisted. He is now treated with somatostatin analog and craniotomy followed by gamma knife surgery is planned. Cushing syndrome should be suspected in cases of early-onset hypertension with symptoms including weight gain, hypokalemia, and bone fracture.

Concomitant thrombosis in patients with cellulitis as incidental finding.

Although inflammation and thrombosis are tightly connected, only 45% of patients with lower leg cellulitis receive anticoagulant therapy. Available data about the prevalence of concomitant deep venous thrombosis (DVT) in patients with cellulitis of the lower extremity is scarce and general guidelines regarding diagnosis and prevention of venous thromboembolism are missing. We sought to determine how frequently DVT occurs as an incidental finding in patients with cellulitis and to provide recommendations for diagnostics and anticoagulant therapy. Patients' records were analysed and 192 consecutive patients with cellulitis were included in this study. The prevalence of concomitant DVT was examined by duplex ultrasound, as well as comorbidities and risk factors. We detected thrombosis in 12.0% of the patients with lower leg cellulitis, of which 43.5% were located in a proximal vein and 52.2% in the veins of the calf. Our results clearly indicate that cellulitis is not only a differential diagnosis, but should be considered a risk factor for venous thrombosis. Therefore, prophylactic anticoagulation should be considered in patients suffering from cellulitis and a systematic screening for venous thrombosis in patients with cellulitis should be performed.

Lower Extremity Edema and Lesions Not Responsive to Conservative Therapy

A 66-year-old man with at least 2 years of progressively worsening unilateral left lower extremity edema and recurrent episodes of cellulitis of the anterior left lower leg, treated repeatedly with diuresis and antibiotic therapy, was referred by his rural family physician to the community paramedic (CP) service for diuresis, compression wrapping, wound care, and self-management education. His medical history included prior stroke with residual left-sided hemiplegia; insulin-treated type 2 diabetes complicated by peripheral neuropathy, retinopathy, and stage 3b chronic kidney disease; and obesity with body mass index 39 kg/m.

PSUN238 COVID 19 induced Type 1 Diabetes Mellitus

Abstract Introduction There have been some case reports where patients presented with uncontrolled hyperglycemia without previous diagnosis of diabetes but very limited literature supporting the fact that COVID 19 infection can lead to the development of new onset Type 1 diabetes. Clinical Case A 30-year-old African American man presented to the office with a diagnosis of new onset DM towards the end of March 2021. He did not have any significant medical history other than prediabetes with a prior HbA1c of 6% and COVID 19 infection in 2020. He had no family history of DM. He was very sick with the COVID 19 infection and lost 20 pounds of weight around that time. He did not get hospitalized and did not have any blood work done. A couple of months after recovery from his COVID 19 illness he developed leg cellulitis. He decided to seek help for this problem and was started on some antibiotics and antifungals, but they did not help much. His leg swelling and pain did not improve so he went to the ER. At that time his work-up showed a HbA1c of 15.5%. Patient was also having polydipsia and polyuria by that time. He was given a new set of antibiotics and was discharged to follow-up with a primary care provider. His PCP started him on Metformin and Lantus insulin for new onset DM2. He was then referred to Endocrinologist for further management. At the time of his endocrine office visit his symptoms of polyuria and polydipsia had improved a lot.His Anti GAD 65 antibodies were positive with a value of 41 (neg <5). C-peptide level was 1.9 which was in the range (1.1-4.4). IAA–2 autoantibodies were positive with a value of more than 120 (neg<7.5). ZNT 8 antibodies and Insulin antibodies were negative. An increase in the number of antibodies is associated with a higher likelihood of type 1 DM. Only less than 3% of type 2 diabetics have positive antibodies. As per the laboratory interpretation our patient had type 1 diabetes. After starting insulin treatment, the HbA1c improved to 6.6% from 15.5%. Patient is currently on continuous glucose monitoring with insulin therapy and has a good glycemic control. Conclusion Our case highlights the importance that SARS-CoV-2 infection is an independent risk factor for the development of new onset type 1 DM and increased risk of complications in preexisting diabetics. There have been studies showing that patients who presented with DKA precipitated by COVID-19 infection had worse outcomes than patient's presenting with DKA without COVID-19 infection. Mortality was higher for COVID-19 in diabetic patients as well. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

P13 A case of Kikuchi-Fujimoto disease triggered by an episode of bacterial cellulitis, associated with features of SLE

P13 A case of Kikuchi-Fujimoto disease triggered by an episode of bacterial cellulitis, associated with features of SLE

A Rare Case of Leech Therapy Induced Right Foot and Leg Cellulitis with Septic Shock

A 57 year old female came to emergency department with complaint ofpain and swelling over right foot and leg distally. On local examination there was multiple scar marks with redness and blisters formation. Patient was also giving complaint of discharge from the site since night yesterday. On further examination the patient was conscious and little drowsy but in arousable state. On further evaluation, the patient was hypotensive with tachycardia andtachypnoea. Patient was known case of Arthritis and Hypothyroidism. On further assessment attendants gave history of Leech therapy over right foot and leg distally since 20 days prior coming to emergency department. The leech therapy was started at an Ayurvedic hospital for detoxification from steroid. Patient was on steroids since long time for arthritis and she was told in ayurvedic hospital that leech therapy will detoxify her blood and remove excess steroids from her body. Patient was immediately taken on to symptomatic supportive treatment with intravenous antibiotics, intravenous fluids and ionotropic support. All relevant investigations sent from emergency department and patient was admitted in Intensive Care Unit for observation. Patient was discharged after 5 days in haemodynamically stable condition.

Relapsing cellulitis associated with Campylobacter coli bacteremia in a Good\u2019s syndrome patient: a case report

BackgroundGood’s syndrome (GS) is characterized by immunodeficiency, and patients diagnosed with GS are susceptible to infection or even bacteremia, which is the most evident complication. Campylobacter coli (C. coli) rarely causes bacteremia or extraintestinal infection. We report herein a case with GS in which right leg cellulitis associated with C. coli bacteremia occurred three times over one and a half years.Case presentationA 41-year-old Chinese male with GS was diagnosed with C. coli infection. He presented with swelling and redness of right lower leg and developed bacteremia due to C. coli repeatedly. Bacteremia was confirmed by bacteriological examination. Adding long-term oral antibiotic treatment with amoxicillin/clavulanate potassium and gentamicin following intravenous meropenem and amikacin was very effective. The blood cultures became negative and the patient has been free from any symptoms encountered for more than one year without relapse of bacteremia.ConclusionsPatients with GS and their physicians should carefully consider the antibacterial treatment options against C. coli bacteremia. Combined anti-infective therapy involving aminoglycoside is preferred in the treatment of C. coli bacteremia in GS patients.

Cutaneous Mucormycosis in an Immunocompetent Child following a Minor Skin Trauma

Cutaneous mucormycosis is a rare infection by the Zygomycetes class of fungi, which carries significant morbidity and mortality. While typically associated in patients with underlying immunocompromise (especially in the current era of COVID-19), it may also be seen in immunocompetent patients. We report a case of a healthy 4-year-old girl with acute right leg cellulitis and abscess formation, who required surgical debridement following poor response to antibiotic therapy and initial incision and drainage. Tissue histopathology returned cutaneous zygomycosis despite negative tissue cultures. At four-week follow-up, her wound was healed well. Clinicians should maintain a high degree of clinical suspicion for cutaneous mucormycosis given its potential for rapidly progressive and disseminated disease. Currently, the mainstay of diagnostic investigations is tissue histopathology, with a growing role for tissue fungal PCR. Treatment involves multidisciplinary management between surgeons and Infectious Diseases team to guide the role for surgical debridement and antifungal therapy.

Successful Treatment of Acute Myeloid Leukemia with CPX-351 in 2 Patients in the United Kingdom during the COVID-19 Pandemic

Introduction: The COVID-19 pandemic hit the United Kingdom in early 2020. High infection rates prompted concern for immunocompromised patients, including patients with AML receiving intensive chemotherapy. CPX-351 (Europe: Vyxeos ® Liposomal; US: Vyxeos ®), a dual-drug liposomal encapsulation of daunorubicin and cytarabine in a synergistic 1:5 molar ratio, is approved for the treatment of newly diagnosed therapy-related AML (t-AML) or AML with myelodysplasia-related changes (AML-MRC) in adults in Europe and in adults and pediatric patients aged ≥1 year in the United States. Despite concerns about intensive chemotherapy-related myelosuppression, the National Cancer Research Institute AML Working Group recommends that CPX-351 should continue to be administered in patients with adverse-risk cytogenetics and/or secondary AML during the pandemic. We report 2 patients with AML who were successfully treated with CPX-351 in the United Kingdom during the COVID-19 pandemic.Methods: The patients were diagnosed and managed per institutional guidelines. Two patients received CPX-351 induction (daunorubicin 44 mg/m 2 + cytarabine 100 mg/m 2) on Days 1, 3, and 5 (Days 1 and 3 for second induction) and CPX-351 consolidation (daunorubicin 29 mg/m 2 + cytarabine 65 mg/m 2) on Days 1 and 3, all by 90-minute IV infusion, during the pandemic.Results: The first patient was a 67-year-old male who presented with generalized fatigue in June 2020 with comorbidities of type 2 diabetes, diabetic nephropathy, and leg ulcers. Blood counts demonstrated a hemoglobin count of 79 g/L, white blood cell count of 0.7×10 9, platelet count of 58×10 9/L, and neutrophil count of 0.2×10 9/L. A bone marrow biopsy revealed AML-MRC with 40% blasts, and the patient had wild-type FLT3, NPM1, and SRSF2. The patient achieved morphologic and cytogenetic remission after 2 CPX-351 induction cycles. The patient then received 1 CPX-351 consolidation cycle but was not a candidate for transplant due to diabetic nephropathy. Tolerability improved with each cycle; the patient experienced neutropenic sepsis during the first induction, a flare up of leg ulcers and cellulitis during the second induction, and no tolerability concerns during the consolidation cycle. After the first induction, recovery of neutrophils and platelets occurred around Day 35 and Day 28, respectively (Figure 1), and counts recovered more quickly with each cycle. This patient was managed without contracting COVID-19 or experiencing any pandemic-related complications.The second patient was a 69-year-old female who presented with pancytopenia in February 2020 with no significant past medical or drug history. Her hemoglobin count was 66 g/L, white blood cell count was 0.6×10 9/L, platelet count was 17×10 9/L, and neutrophil count was 0.3×10 9/L. The patient was diagnosed with AML-MRC with mutated NPM1, SRSF2, IDH2, and JA2. During the first CPX-351 induction cycle, the patient contracted COVID-19. Some symptoms were present, but the patient did not become significantly unwell from COVID-19. Despite count recovery, the patient remained positive by nasal/oral PCR swab test for several weeks, delaying the delivery of the second CPX-351 induction cycle. After the second CPX-351 cycle began, the patient once again became positive for COVID-19 by PCR swab. The patient remained positive for longer than the first infection but was largely asymptomatic during the cycle (apart from a bout of sepsis). After a period of approximately 3 months from the previous CPX-351 cycle, the patient received a CPX-351 consolidation cycle and achieved complete remission with no measurable residual disease by NPM1 mutation in the bone marrow (Figure 2). The patient was eligible for transplant but declined.Conclusions: Two patients with AML-MRC were successfully treated with CPX-351 during the COVID-19 pandemic, despite one of the patients contracting and variably testing positive for the disease. During the pandemic, it is important to weigh the benefits of treating AML with curative intent versus the risks of immunosuppression and potential COVID-19 infection. Individualized decisions must be made for each patient based on disease, treatment, and COVID-19 risk factors through discussion with a multidisciplinary team. Although treating patients with AML with CPX-351 during the pandemic can be challenging, it remains an option for appropriate patients with newly diagnosed t-AML or AML-MRC. [Display omitted] DisclosuresMunisamy: Roche: Speakers Bureau; Jazz Pharmaceuticals: Speakers Bureau. Choudhuri: AstraZeneca, Bristol-Myers Squibb, Jazz Pharmaceuticals, and Pfizer: Consultancy.

Supermicrosurgical lymphovenous anastomosis for the treatment of recurrent cellulitis-associated lymphedema in the lower limb

Recurrent leg cellulitis can damage the lymphatic system and result in chronic lymphedema. Antibiotic therapy is administered to prevent cellulitis; however, antibiotic-resistant bacteria frequently occur. Supermicrosurgical lymphovenous anastomosis (LVA) can play a role in stopping the vicious circle by improving lymph circulation. In the present report, we have described the case of a 40-year-old male patient with frequent cellulitis and subsequent left leg edema. Based on the lymphoscintigraphy findings, LVA was performed on the left leg (six anastomoses). One year later, the lymphedema had subsided without further cellulitis. Lymphoscintigraphy revealed no dermal backflow. Thus, LVA is a treatment option for recurrent cellulitis-associated lymphedema.

1172 Maggot Debridement Therapy (MDT) In Treating Group A Streptococcus Necrotizing Fasciitis of The Lower Limb as A Part of Multimodal Therapy

Abstract Background Medical-grade maggots have been commercially available recently and today there is a resurge interest in MDT. They are approved for debridement of wounds with necrotic tissue, including pressure ulcers, venous ulcers. However, for necrotising fasciitis, it has been used with precaution due to the complexity of the disease. In our practice, Maggot debridement therapy (MDT) has been proven to be very effective in the treatment of gram-positive bacterial infections. Worldwide, Case reports on the results of 15 patients with necrotizing fasciitis treated with MDT have been reported. However, in current practice, Maggot Debridement therapy has not been widely applied. Case presentation A 63-year-old lady admitted to a general surgery ward with uncomplicated cellulitis of the right leg. After 2 days, the patient then was diagnosed with Necrotising fasciitis which was treated with wound debridement. Postoperative histopathology specimen confirmed necrotizing fasciitis V.A.C. VERAFLO™ Therapy was used postoperatively followed by two more debridement sessions. To reduce the need for further surgical debridement Maggot Debridement Therapy was started. Over the next 3 weeks, six sessions of Maggot Debridement therapy were applied to the infected area. Skin grafting then was performed 3 months later. The patient then discharged home with regular surgical fellow up. Conclusions NF is a complex disease, associated with high morbidity and mortality. Multimodal therapies are essential to achieve aggressive yet conservative wound debridement with preservation of viable tissue. This case report showed that MDT is a feasible, safe, cost-effective option that to be added to the other treatment modalities

Fungal, Bacterial, and Viral Infections of the Skin

The skin can become infected by viruses, fungi, and bacteria, including some that ordinarily are harmless colonizing organisms. The most common fungal infections are caused by dermatophytes, which can involve the hair, nails, and skin. Potassium hydroxide (KOH) preparations of specimens from affected areas typically demonstrate hyphae, and either topical or systemic antifungal therapy usually cures or controls the process. The most common bacterial pathogens are Staphylococcus aureus and group A streptococci, which, alone or together, can cause a wide variety of disorders, including impetigo, ecthyma, and cellulitis. Topical antibiotics may suffice for impetigo, but ecthyma and cellulitis require systemic treatment. S. aureus, including methicillin-resistant strains, can also cause furuncles, carbuncles, and cutaneous abscesses. For these infections, incision and drainage without antibiotics are usually curative. Warts are the most common cutaneous viral infection, and eradication can be difficult, especially where the skin is thick, such as the palms and soles, or the patient is immunocompromised. Most therapies consist of trying to destroy the viruses by mechanical, chemical, or immune mechanisms. This review covers dermatophyte infections, yeast infections, bacterial infections, and viral infections of the skin. Figures show the classic annular lesion of tinea corporis, a typical kerion presenting as a zoophilic Microsporum canis infection of the scalp (tinea capitis), tinea corporis, tinea barbae, tinea pedis between and under the toes and on the plantar surface, inflammatory tinea pedis, tinea unguium, tinea manuum, angular cheilitis, prominent satellite lesions of discrete vesicles associated with candidiasis, facial candidiasis, Candida paronychia, tinea versicolor, nonbullous impetigo, bullous impetigo, ecthyma, leg cellulitis, erythema and edema on the cheeks, eyelids, and nose, furuncle, carbuncle, nasal folliculitis, pitted keratolysis, trichomycosis axillaris, necrotizing fasciitis, Fournier gangrene, folliculitis, plantar wart, condyloma acuminatum, and benign lesions of bowenoid papulosis. Tables list dermatophyte species, terminology of dermatophyte infections, topical agents for dermatophyte infections, treatment options for impetigo (adult doses), and treatment options for erythrasma. This review contains 29 figures, 12 tables, and 36 references Keywords: Staphylococcus aureus, methicillin-resistant strains, furuncles, carbuncles, cutaneous abscesses, dermatophytes, zoophilic Microsporum canis, andidiasis, facial candidiasis, Candida paronychia, tinea versicolor, nonbullous impetigo, bullous impetigo, ecthyma, leg cellulitis, erythema

Fungal, Bacterial, and Viral Infections of the Skin

The skin can become infected by viruses, fungi, and bacteria, including some that ordinarily are harmless colonizing organisms. The most common fungal infections are caused by dermatophytes, which can involve the hair, nails, and skin. Potassium hydroxide (KOH) preparations of specimens from affected areas typically demonstrate hyphae, and either topical or systemic antifungal therapy usually cures or controls the process. The most common bacterial pathogens are Staphylococcus aureus and group A streptococci, which, alone or together, can cause a wide variety of disorders, including impetigo, ecthyma, and cellulitis. Topical antibiotics may suffice for impetigo, but ecthyma and cellulitis require systemic treatment. S. aureus, including methicillin-resistant strains, can also cause furuncles, carbuncles, and cutaneous abscesses. For these infections, incision and drainage without antibiotics are usually curative. Warts are the most common cutaneous viral infection, and eradication can be difficult, especially where the skin is thick, such as the palms and soles, or the patient is immunocompromised. Most therapies consist of trying to destroy the viruses by mechanical, chemical, or immune mechanisms. This review covers dermatophyte infections, yeast infections, bacterial infections, and viral infections of the skin. Figures show the classic annular lesion of tinea corporis, a typical kerion presenting as a zoophilic Microsporum canis infection of the scalp (tinea capitis), tinea corporis, tinea barbae, tinea pedis between and under the toes and on the plantar surface, inflammatory tinea pedis, tinea unguium, tinea manuum, angular cheilitis, prominent satellite lesions of discrete vesicles associated with candidiasis, facial candidiasis, Candida paronychia, tinea versicolor, nonbullous impetigo, bullous impetigo, ecthyma, leg cellulitis, erythema and edema on the cheeks, eyelids, and nose, furuncle, carbuncle, nasal folliculitis, pitted keratolysis, trichomycosis axillaris, necrotizing fasciitis, Fournier gangrene, folliculitis, plantar wart, condyloma acuminatum, and benign lesions of bowenoid papulosis. Tables list dermatophyte species, terminology of dermatophyte infections, topical agents for dermatophyte infections, treatment options for impetigo (adult doses), and treatment options for erythrasma. This review contains 29 figures, 12 tables, and 36 references Keywords: Staphylococcus aureus, methicillin-resistant strains, furuncles, carbuncles, cutaneous abscesses, dermatophytes, zoophilic Microsporum canis, andidiasis, facial candidiasis, Candida paronychia, tinea versicolor, nonbullous impetigo, bullous impetigo, ecthyma, leg cellulitis, erythema

Fungal, Bacterial, and Viral Infections of the Skin

The skin can become infected by viruses, fungi, and bacteria, including some that ordinarily are harmless colonizing organisms. The most common fungal infections are caused by dermatophytes, which can involve the hair, nails, and skin. Potassium hydroxide (KOH) preparations of specimens from affected areas typically demonstrate hyphae, and either topical or systemic antifungal therapy usually cures or controls the process. The most common bacterial pathogens are Staphylococcus aureus and group A streptococci, which, alone or together, can cause a wide variety of disorders, including impetigo, ecthyma, and cellulitis. Topical antibiotics may suffice for impetigo, but ecthyma and cellulitis require systemic treatment. S. aureus, including methicillin-resistant strains, can also cause furuncles, carbuncles, and cutaneous abscesses. For these infections, incision and drainage without antibiotics are usually curative. Warts are the most common cutaneous viral infection, and eradication can be difficult, especially where the skin is thick, such as the palms and soles, or the patient is immunocompromised. Most therapies consist of trying to destroy the viruses by mechanical, chemical, or immune mechanisms. This review covers dermatophyte infections, yeast infections, bacterial infections, and viral infections of the skin. Figures show the classic annular lesion of tinea corporis, a typical kerion presenting as a zoophilic Microsporum canis infection of the scalp (tinea capitis), tinea corporis, tinea barbae, tinea pedis between and under the toes and on the plantar surface, inflammatory tinea pedis, tinea unguium, tinea manuum, angular cheilitis, prominent satellite lesions of discrete vesicles associated with candidiasis, facial candidiasis, Candida paronychia, tinea versicolor, nonbullous impetigo, bullous impetigo, ecthyma, leg cellulitis, erythema and edema on the cheeks, eyelids, and nose, furuncle, carbuncle, nasal folliculitis, pitted keratolysis, trichomycosis axillaris, necrotizing fasciitis, Fournier gangrene, folliculitis, plantar wart, condyloma acuminatum, and benign lesions of bowenoid papulosis. Tables list dermatophyte species, terminology of dermatophyte infections, topical agents for dermatophyte infections, treatment options for impetigo (adult doses), and treatment options for erythrasma. This review contains 29 figures, 12 tables, and 36 references Keywords: Staphylococcus aureus, methicillin-resistant strains, furuncles, carbuncles, cutaneous abscesses, dermatophytes, zoophilic Microsporum canis, andidiasis, facial candidiasis, Candida paronychia, tinea versicolor, nonbullous impetigo, bullous impetigo, ecthyma, leg cellulitis, erythema

ARE SPORTS INJURIES THE MOST COMMON CAUSE OF MOREL-LAVALLEE LESIONS IN THE PEDIATRIC POPULATION?

Background:Traumatic internal degloving injury i.e. Morel-Lavallée lesion (MLL) develops as a result of blunt trauma with tangential shear forces. In the pediatric population, these have been described only as small case reports till date. Purpose: To describe the largest case series of lower extremity Morel-Lavallée lesion (MLL) in the pediatric population, to determine its etiology (especially its relationship to sports), treatment and outcomes.Methods:Retrospective study of patients <18 years presenting to a tertiary children’s hospital with MLL between 2013-2019. Demographics, clinical data, imaging features, treatment and outcomes data was collected. Descriptive statistical analysis was conducted.Results:38 patients (21 males, 17 females) having MLL with mean age 14.6 years were classified into 2 groups- hip/thigh MLL (9 patients) and lower leg MLL (29) (Table 1.1). Most common cause of lower leg MLL was sports injury (79%). Most commonly implicated sports in MLL were football and baseball(24% each). Associated injuries were seen in 9 (23%) patients. Radiographs done in 58% of patients showed no bony abnormalities. Imaging modality of choice was MRI for lower leg MLLs (72%) and US for hip/thigh MLL (67%)(Fig.1.2). MLL size was larger for hip/thigh MLL (168 cm3) as compared to leg MLL (38.6 cm3). 25 (65.8%) of MLLs were treated with conservative management,12 (31.5%) with minimally invasive methods and 1(2.6%) needed surgical management. 2/9 (22.2%) of the associated injuries required operative management. 2/38 (5%) patients were given prophylactic antibiotics. 72.4% Lower leg MLLs were treated with conservative management while intervention was needed more in hip/thigh MLLs (55.6%). Patients returned to activities at 14.3 weeks for hip/thigh MLL;9.1 weeks for lower leg MLL. 24 patients with adequate documentation demonstrated lower extremity functional score (LEFS) and pain level of 74/80 (92.5%) and 0.7/10 respectively at mean 12.5 months follow-up. Leg cellulitis was seen as a complication in one patient.Conclusion:The largest case series on MLL exclusively in the pediatric population suggests that they are more common in knee/leg region region and usually caused by sports injuries which is notably different as compared to adult population. Most pediatric injuries are treated conservatively, especially sports related MLLs. Although return to activities takes longer for hip/thigh injuries, majority of patients regain satisfactory functionality post-injury.Table 1.1.Figure 1.2.MLL imaging – MRI and Ultrasound features of MLL

HVAD Decommission in a Failing Mustard: Making Virtue out of Necessity

Introduction Ventricular assist device (VAD) for systemic right ventricular failure (SRVF) in transposition of the great arteries (TGA) patients has proven useful to reduce transpulmonary gradient (TPG) and bridge-to-transplantation. Tricuspid valve replacement (TVR) at the time of implant to address severe tricuspid regurgitation (TR) may be beneficial to achieve optimal unloading of the systemic right ventricle (SRV). We report successful decommissioning of a SRV VAD following device thrombosis in a patient who underwent TVR at VAD implant. Case Report A 37-year-old man who underwent a Mustard procedure for TGA at 10 months of age presented with acute heart failure, triggered by leg cellulitis and pulmonary embolism. He was found to have a severely impaired SRV, severe TR and a dilated and moderately impaired subpulmonic left ventricle (LV). Despite medical management and anticoagulation, he worsened requiring admission to the ICU for inotropic support. A right heart catheter (RHC) showed a mean pulmonary artery (PA) pressure of 48 mmHg and TPG of 15 mmHg, therefore ineligible for heart transplant. He underwent successful HeartWare-VAD implantation into his failing SRV with concomitant systemic TVR. His post-operative course was uneventful and he was discharged after 25 days. After six months, his TPG came down to 4 mmHg and he was listed for heart transplantation. He remained stable and free from VAD complications until he presented with thrombosis of the outflow graft after 27 months. Anticoagulation with bivalirudin was started without success and persistent reduced VAD flow of Summary VAD implantation is a feasible strategy for those with SRVF. Concomitant TVR to address severe TR may have additional benefit and in this particular case, likely to have contributed to successful VAD decommissioning following device thrombosis.