Necrotic Skin Lesions Research Articles

Rapidly evolving necrotic skin lesions of the face

Rapidly evolving necrotic skin lesions of the face

Characterization of Risk Factors for Calciphylaxis in Hemodialysis Patients in the Fraser Health Renal Program – A Matched Case-Control Retrospective Review

Introduction: Calciphylaxis is a lethal and rare disease characterized by ischemic and necrotic skin lesions caused by vascular calcification of adipose tissue. There have been many risk factors analyzed in the literature; however, the pathogenesis of calciphylaxis is still not well understood and treatment options are limited due to the lack of interventional studies. Our objectives were to describe risk factors, prevalence, incidence, and outcomes for calciphylaxis in hemodialysis patients within the Fraser Health Renal Program. Methods: This was a retrospective matched case-control study of hemodialysis patients within the Fraser Health Renal Program. Hemodialysis patients with calciphylaxis were matched to hemodialysis patients without calciphylaxis in a 1:2 ratio for age and sex from September 2, 2017 to July 3, 2020. Findings: There was a total of 40 calciphylaxis cases matched to 80 controls. In the univariate analysis, peritoneal dialysis, higher body mass index, lower serum iron, lower transferrin saturation, sevelamer, cinacalcet, warfarin, iron (PO), and insulin were associated with increased risk of calciphylaxis. In the multivariate analysis, only peritoneal dialysis, serum iron, sevelamer, and warfarin were identified as significant and strong risk factors associated with calciphylaxis. A low prevalence of 1.9% and high mortality rate of 57.5% at 12 months was found for calciphylaxis cases. Discussion: Significant risk factors associated with calciphylaxis were peritoneal dialysis, serum iron, sevelamer, and warfarin. Future studies should further investigate the impact of minimizing exposure to these risk factors to reduce calciphylaxis development.

Disseminated Fusarium infection in an immunocompromised patient Successful outcome with combined antifungal therapy

Fusarium species are plant pathogens which exist ubiquitously in the environment. While they can cause superficial and subcutaneous infections in healthy individuals, they can give rise to deep and disseminated infections in immunocompromised patients, particularly in patients with haematological malignancies with a high risk of mortality. This case describes a young male diagnosed with B cell Acute Lymphoblastic Leukaemia (B-ALL) who developed disseminated Fusarium infection with febrile neutropenia following induction chemotherapy. Necrotic skin lesions led to the diagnosis in this patient. Though the patient had a clinical recurrence of infection due to inadequate treatment initially, he was finally completely cured with combined antifungal therapy using amphotericin B and voriconazole.

Multisystem inflammatory syndrome in neonate with skin lesions—A rare case report

Multisystem inflammatory syndrome in children is a serious condition that occurs due to postinfectious immune-mediated hyperinflammatory reaction seen in children, which develops after 4–6 weeks of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection; it is rare in neonates. We present here a case of a term newborn with fever, respiratory distress, and necrotic skin lesion that gradually progressed to multisystem dysfunction. Reverse transcription polymerase chain reaction for SARS-CoV-2 was negative for both mother and the baby. SARS-CoV-2 IgG titer was negative in the mother but was found to be positive in the newborn. The diagnosis of multisystem inflammatory syndrome in neonate was made and was successfully treated with intravenous immunoglobulin and corticosteroids.

A Rare Case of Acute Infectious Purpura Fulminans Caused by Klebsiella Pneumoniae and Human Herpesvirus Type 5

BackgroundPurpura fulminans (PF), a rare, life-threatening disorder, is a hematological emergency in which there is skin necrosis, disseminated intravascular coagulation (DIC), and protein C deficiency. In PF, the skin necrosis and DIC are secondary to protein C deficiency. This may progress rapidly to multiorgan failure caused by the thrombotic occlusion of small- and medium-sized blood vessels.Case ReportThis article presents the case of a 22-year-old male with fever as well as necrotic and purpuric skin lesions. The ultrasound and computed tomography scans revealed infections in the skin wounds as well as venous microthrombosis and thrombosis in multiple intracranial and pulmonary vessels. The laboratory tests showed signs of sepsis, thrombocytopenia, an abnormal decrease in protein C and antithrombin III, DIC, multiple organ and system failures, gastric varices, and gastrointestinal hemorrhage. The blood, sputum, and secretions under the skin lesions were cultured and were positive for Klebsiella pneumoniae. The results of the high-throughput genetic testing of the pathogenic microorganism DNA were consistent. In addition, human herpesvirus type 5 was detected. The histopathological examination of the skin lesions revealed pathological features consistent with PF. After successful treatment by the departments of Dermatology, Emergency Critical Care Medicine, and the Intensive Care Unit, the patient was discharged after 67 days of hospitalization.ConclusionAdults with acquired protein C and/or S deficiency states, including certain bacterial and viral infections, who drink alcohol and take varieties of non-steroidal anti-inflammatory analgesics at the same time, may develop acute infectious PF. Clinicians should be aware of this for early diagnosis and treatment.

Disseminated Fusariosis with Secondary Hemophagocytic Lymphohistiocytosis

We report here a 7-year girl with B-Acute Lymphoblastic Leukemia (ALL) on Berlin Frankfurt Munster (BFM) based induction chemotherapy who presented with fever, cough, and painful necrotic skin lesions simulating pseudomonas sepsis. The patient was eventually diagnosed with disseminated fusariosis. While on combination antifungal therapy, fever reappeared with pancytopenia and hepatosplenomegaly, and she was subsequently diagnosed with secondary Hemophagocytic lymphohistiocytosis (HLH) and was treated using the HLH 2004 protocol. The child responded to treatment well. This report highlights the high index of clinical suspicion, appropriate investigations needed to diagnose fusariosis and secondary HLH in pediatric oncology practice promptly, and the successful treatment outcome despite having them both.

Pyoderma gangrenosum in a grade 3 open fracture after a forest accident : When one cannot see the wood for the trees

We describe the case of aforest worker with aGustilo-AndersonIII dislocation fracture of the ankle joint. After initial external fixation, round necrotic skin lesions with hyperemic border walls appeared on the entire lower leg. Recurrent débridements worsened the soft tissue instead of improving it. An immunoglobulin and corticosteroid treatment was initiated, which diminished the inflammatory reaction and granulation of soft tissue began. Posttraumatic pyoderma gangrenosum is arare diagnosis. Nevertheless, it needs to be on the list of differential diagnoses if uncommon soft tissue reactions appear.

Lucio Phenomenon: A Rare Type of Leprosy Reaction

Introduction: Leprosy is an infectious disease caused by Mycobacterium leprae (M. leprae), which affects the skin and peripheral nerves. Lucio phenomenon is a rare leprosy reaction characterized by severe necrotizing skin lesions. This case report aims to provide clinicians with more information regarding the rare Lucio phenomenon.Case: A 53-year-old male patient presented with worsening lesions on both lower limbs. Physical examination revealed bilateral madarosis and saddle nose. Multiple erythematous lesions with deep ulceration, multiple necrotic tissues, and bilateral extremities deformities were found. There were amputations of the right hand’s digits III and V and left hand’s digits V. Decreased sensory function was found in the median, ulnar and posterior tibial nerves. Acid-fast bacilli (AFB) staining revealed bacterial index (BI) +3 and morphological index (MI) 10%. Histopathological examination showed foamy macrophages, leukocytoclastic vasculitis, lobular panniculitis, and diffuse multiple perivascular infiltrates. It also had extensive areas of necrosis with diffuse neutrophil infiltrate in the deep layer of the dermis and the globes in macrophages. The patient was diagnosed with the Lucio phenomenon and given treatment in the form of Multi-Drug Therapy (MDT) for its multibacillary leprosy, corticosteroids, antibiotics, and wound care. The patient died on the 18th day of treatment.Conclusion: Early detection is necessary to start the treatment immediately and prevent disease worsening. Although MDT and corticosteroid treatment effectively ameliorates the lesions of the Lucio phenomenon, this patient had extensive skin and nerve involvement, secondary infection, and anemia. These resulted in a poor prognosis and increased morbidity.

ANCA Associated vasculitis- A case of microscopic polyangiitis with proliferative glomerulonephritis

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) are a collection of diseases, characterised by destruction and inflammation of small and medium vessels. Microscopic Polyangiitis (MPA) is part of an ANCA-associated vasculitis (AAV).The clinical signs diverge and disturba number of organs such as the kidneys, lungs, stomach and intestine. Skin manifestations such as purpuric, urticarial, nodular, ulcerative, livedoid and necrotic skin lesions were common as in other vaso-occlusive disorder. Morphology and added features aid the diagnostic approach. Here, we report a diagnostically challenging case of microscopic polyangiitis with progressive glomerulonephritis.

527 Late-Breaking: Objective Assessment of Behaviour, Pain, and Lameness Due to Digital Dermatitis in Beef Cattle

Abstract Digital dermatitis (DD) is an infectious disease affecting cattle feet causing ulcerative and necrotic skin lesions. Most lesions are painful when palpated, some cause lameness and significantly impact animal welfare and productivity. Our objectives were: to determine if changes in behaviour were associated with DD in cattle, to quantify pain associated with DD lesions, and to determine the relationship between pain sensitivity and lameness, and DD and lesion temperature. In total, 255 animals across three feedlots were enrolled. A subset of 120 animals were fitted with accelerometers to record behaviour. Cattle were scored for lameness (Step-Up Locomotion Scoring System), both hind feet scored for DD (M-stage scoring system), the pressure pain threshold of lesions determined using pressure algometry and lesion temperature using thermal images. Animals and feet were classified as DD absent or present. Further, DD present was divided into active or chronic. Behaviour, 5 to 2 days before DD identification was analyzed. Animals with DD ruminated 3% less daily compared to animals without DD (P < 0.05). Further, animals with active lesions ruminated 5% less daily (P < 0.05). Daily inactivity time was greater in animals with DD and the effect of day depended on type of lesion (P < 0.05). Feet without DD lesions withstood 5.6N more pressure (P < 0.001). Active lesions were most sensitive withstanding 8.1N less pressure and chronic lesions 4.1N less pressure than DD absent feet (P < 0.05). Moderate to severely lame animals withstood 3.1N less pressure than sound animals (P < 0.001). Median maximum temperature (MMT) was higher in feet with DD compared to those without (P < 0.001) with MMT being highest in active lesions (P < 0.05). In conclusion, rumination is depressed, and inactivity increased in DD affected animals. Both active and chronic lesions are painful, lame animals have a lower pain threshold and DD is associated with higher lesion temperatures.

Leishmania major cause of a cutaneous leishmaniasis in a car driver from east Azerbaijan province: A case report

Background: Leishmaniasis is a zoonotic disease and its the known as a health problem in all of the world. Case presentation: The patient, a 47-year-old man car driver from city of Bostan abad, with a history of traveling to cutaneous leishmaniasis endemic provinces last year, was referred to city health center with a 17 mm, no discharge and pus with necrotic appearance skin lesion. Biochemical, hematological parameters and urine culture and analysis were normal. Three smears was prepared with sterile vaccinostyle from the margins of wound and transferred to specific medium in sterile conditions. After staining the prepared smears from the wound, amastigotes with large nucleus and small kinetoplast in macrophages and active promastigotes in the liquid phase of medium were observed. Polymerase chain reaction (PCR) was performed using ITS-1 by specific primers. In the PCR product electrophoresis were compared with the marker bands and 350 bp band weight determined. With electrophoretic pattern and comparison with positive control band, isolates parasites belonged to Leishmania genus. In order to definitively diagnose the parasite species, sequencing method was used. The results showed 99% homology with Leishmania major. Finally, the patient with a diagnosis of rural cutaneous leishmaniasis was induction with Glucantime drug. Conclusion: Diagnosis of suspected cases with cutaneous leishmaniasis is the major importance. If an infected patient is diagnosed in the early stages of the disease, can be prevented the extent of the scar after recovery, as well as the possible complications of rural infection.

Necrotic Sequelae of COVID-19 Vasculitis in Geriatric Patient

COVID-19 vasculitis has recently been reported in COVID-19 articles. Cutaneous manifestations can progress to necrotic skin lesion in 6% of cases. This is theoretically linked with advanced age and severe degree of infection. (1) This is a case of a 90-year-old female from a care home with a background history of dementia, heart failure, hypothyroidism, diabetes and pacemaker-in-situ. She presented with fever and tachycardia. COVID-19 test turned out positive. Electrocardiogram (ECG) showed atrial fibrillation with rapid ventricular response of spontaneous resolution. Several days later, she had recurrent supraventricular tachycardia which was resolved by adenosine. The day after, she developed multiple petechiae on hands, feet and nose. Among differentials made were infective endocarditis, heparininduced thrombocytopenia and idiopathic thrombocytopenic purpura. Full blood count revealed thrombocytopenia with p-anca positive on vasculitis screen. The lesions progressed into necrotic skin breakdown, which was unaesthetically pleasant for the patient. Final diagnosis by a Geriatrician was COVID-induced vasculitis. Multidisciplinary team (MDT) consisted of Cardiology, Haematology, Dermatology, Rheumatology and Plastic Surgery were involved in decision-making for investigations and treatment. COVID-19 vasculitis in this case possibly augmented by other factors. The pre-existing heart failure may act as cardiovascular risk factor, predisposing to systemic vascular failure thus intensifies thrombosis. (1) Besides that, can it be aggravated by hypothyroidism whereby autoimmunity is the precursor? This case holds impactful clinical significance, opening doors to future research and audit. MDT involvement is highly valued thus magnifying quality of patient care and safety. Together with comprehensive geriatric assessment where physical, functional, mental, social and environmental factors are taken into management.International Journal of Human and Health Sciences Supplementary Issue-2: 2021 Page: S10

Varicella gangrenosa: A rare chickenpox complication

Varicella gangrenosa is a rare but life-threatening dermatological complication of infection with varicella-zoster virus. A healthy 37-year-old male who had been diagnosed with varicella 20 days back was admitted to our hospital with complaints of fever and painful necrotic skin lesions. Physical examination revealed multiple round to oval ulcers covered with eschar predominantly over arms, lower limbs, back of trunk and flanks. Streptococcus pyogenes and Staphylococcus aureus grew in wound culture. Biopsy revealed ulceration and necrosis of epidermis, and edema, hemorrhage and granulation tissue formation involving the dermis and subcutaneous tissue. The patient was treated with acyclovir - parenteral followed by oral, antibiotics and supportive measures. The lesions healed and he was discharged after 20 days. We report this case to draw attention to the fact that varicella gangrenosum, even though a rare complication, may occur in the lesions of chicken pox and that the survival of patient depends on early diagnosis and aggressive treatment.

Vasculitis leucocitoclásticas como manifestación extraintestinal dermatológica rara de la enfermedad inflamatoria intestinal asociada con Clostridium: reporte de un caso

Las vasculitis leucocitoclásticas se definen como el daño e inflamación de las paredes vasculares, son aquellas vasculitis de pequeños vasos que anatomopatológicamente presentan leucocitoclasia y puede observarse como una manifestación extraintestinal de la enfermedad inflamatoria intestinal. En la colitis ulcerativa se presentan en menor frecuencia, por inmunocomplejos generados en la mucosa intestinal debido a la exposición del tejido linfoide submucoso a antígenos fecales; podrían precipitarse en las paredes de los pequeños vasos. Se pueden asociar con Clostridium difficile, que es un bacilo grampositivo esporulado, anaerobio estricto, que se encuentra normalmente en el medio ambiente y produce colitis, que se manifiesta como un cuadro diarreico presentado después de la ingesta de antibióticos y altera la flora bacteriana común de este órgano. El caso se trata de un paciente 36 años de edad con cuadro de diarreas líquidas con moco y escaso sangrado; se realizó un estudio endoscópico y anatomopatológico en el que se observó colitis ulcerativa con coproparasitario positivo para antígeno de C. difficile, y en su hospitalización presentó lesiones dérmicas petequiales y necróticas en el cuarto dedo de la mano izquierda, que en la biopsia dio como resultado vasculitis de pequeños vasos. En este artículo se revisan de forma práctica los aspectos relacionados con la fisiopatología, histología, tratamiento y diagnósticos de la manifestación extraintestinal dermatológica rara, como la vasculitis leucocitoclástica en pacientes con colitis ulcerativas asociadas con Clostridium.

An Eschar-like souvenir from a journey to Colombia: Ecthyma gangrenosum as a differential diagnosis of tropical diseases in immunocompromised patients \u2013 a case report

BackgroundEcthyma gangrenosum (EG) is a cutaneous infectious disease characterized by eschar-like skin ulcers typically caused by Pseudomonas aeruginosa. Here, we report a case of relapsing EG in a patient who had returned from a trip to Colombia, thus establishing EG as an important differential diagnosis of tropical diseases, and demonstrating that even long-term antibiotic treatment can result in only partial remission of EG.Case presentationA 77-year-old man with underlying chronic lymphocytic leukemia (CLL) on ibrutinib treatment was admitted because of a superinfected mosquito bite on the left ear and multiple partially necrotic skin lesions disseminated all over the entire body five days after returning from a trip to Colombia. The initial clinical suspicion of a tropical disease (leishmaniosis, systemic mycosis, or others) could not be confirmed. During the diagnostic workup, microbiological cultures of the skin biopsies and bronchoalveolar lavage revealed Pseudomonas aeruginosa, leading to a diagnosis of EG. Initial antibiotic treatment resulted in partial remission. However, the patient had to be re-admitted due to a relapse 3–4 weeks after the first episode. Finally, the patient was successfully treated with a combined approach consisting of antibiotics, recurrent surgical incisions, and administration of immunoglobulins.ConclusionsIn conclusion, EG should be considered as a differential diagnosis in immunosuppressed patients presenting with eschar-like skin ulcers. A combined treatment approach seems to be the best choice to achieve clinical cure and avoid relapse.

Coagulase-negative staphylococci release a purine analog that inhibits Staphylococcus aureus virulence

Coagulase-negative staphylococci and Staphylococcus aureus colonize similar niches in mammals and conceivably compete for space and nutrients. Here, we report that a coagulase-negative staphylococcus, Staphylococcus chromogenes ATCC43764, synthesizes and secretes 6-thioguanine (6-TG), a purine analog that suppresses S. aureus growth by inhibiting de novo purine biosynthesis. We identify a 6-TG biosynthetic gene cluster in S. chromogenes and other coagulase-negative staphylococci including S. epidermidis, S. pseudintermedius and S. capitis. Recombinant S. aureus strains harbouring this operon produce 6-TG and, when used in subcutaneous co-infections in mice with virulent S. aureus USA300, protect the host from necrotic lesion formation. Used prophylactically, 6-TG reduces necrotic skin lesions in mice infected with USA300, and this effect is mediated by abrogation of toxin production. RNAseq analyses reveal that 6-TG downregulates expression of genes coding for purine biosynthesis, the accessory gene regulator (agr) and ribosomal proteins in S. aureus, providing an explanation for its effect on toxin production.

COVID-19 vasculitis and novel vasculitis mimics.

COVID-19 has been occasionally linked to histologically confirmed cutaneous vasculitis and a Kawasaki-like vasculitis, with these entities generally having minimal or no lung involvement and a good prognosis. Unlike these vasculitis types, patients with severe COVID-19 pneumonia can develop cutaneous vasculitis-like lesions and systemic arterial and venous thromboemboli, including cryptogenic strokes and other vasculopathy features. Proposed underlying mechanisms for these severe manifestations have encompassed immune dysregulation, including an anti-phospholipid syndrome-like state, complement activation, viral dissemination with direct systemic endothelial infection, viral RNAaemia with immunothrombosis, clotting pathway activation mediated by hypoxaemia, and immobility. In this Viewpoint, we highlight how imaging and post-mortem findings from patients with COVID-19 indicate a novel thrombosis in the pulmonary venous territory distal to the alveolar capillary bed, a territory that normally acts as a clot filtration system, which might represent an unappreciated nidus for systemic microembolism. Additionally, we suggest that this mechanism represents a novel vasculitis mimic related to COVID-19 that might lead to cryptogenic strokes across multivessel territories, acute kidney injury with haematuria, a skin vasculitis mimic, intestinal ischaemia, and other organ ischaemic manifestations. This finding is supported by pathological reports of extensive pulmonary venular thrombosis and peripheral organ thrombosis with pauci-immune cellular infiltrates. Therefore, severe COVID-19 pneumonia with extensive pulmonary intravascular coagulopathy might help to explain the numerous systemic complications of COVID-19, in which the demonstration of direct organ infection has not adequately explained the pathology.

Genotype I African swine fever viruses emerged in domestic pigs in China and caused chronic infection

ABSTRACT The Georgia-07-like genotype II African swine fever virus (ASFV) with high virulence has been prevalent in China since 2018. Here, we report that genotype I ASFVs have now also emerged in China. Two non-haemadsorbing genotype I ASFVs, HeN/ZZ-P1/21 and SD/DY-I/21, were isolated from pig farms in Henan and Shandong province, respectively. Phylogenetic analysis of the whole genome sequences suggested that both isolates share high similarity with NH/P68 and OURT88/3, two genotype I ASFVs isolated in Portugal in the last century. Animal challenge testing revealed that SD/DY-I/21 shows low virulence and efficient transmissibility in pigs, and causes mild onset of infection and chronic disease. SD/DY-I/21 was found to cause necrotic skin lesions and joint swelling. The emergence of genotype I ASFVs will present more problems and challenges for the control and prevention of African swine fever in China.

Hydroa Vacciniforme-Like Lymphoproliferative Disorder in Korea: Prognostic Implication of Clinical Signs and Whole Blood Epstein-Barr Virus DNA.

BackgroundHydroa vacciniforme-like lymphoproliferative disorder (HVLPD) is rare Epstein-Barr virus (EBV)-associated disease. The classic form of HVLPD is a self-resolving disease, whereas the systemic form can progress to malignant lymphoma, resulting in fatal outcomes. However, the prognostic factors remain unclear.ObjectiveThis study aimed to evaluate the clinical characteristics of HVLPD and the association between whole blood EBV DNA and clinical outcomes.MethodsWe retrospectively reviewed our 25-year experience involving 11 patients with HVLPD from a single tertiary center in South Korea and evaluated the clinical characteristics of HVLPD and the correlation between whole blood EBV DNA and clinical outcomes.ResultsOf the total 11 patients, 54.5% (6/11) manifested classic HVLPD that resolved with conservative treatment, while 45.5% (5/11) patients had systemic HVLPD, four of whom died of progressive disease or hemophagocytic syndrome. Five patients with systemic HVLPD manifested severe skin lesions such as prominent facial edema, deep ulcers and necrotic skin lesions involving sun-protected areas. Median EBV DNA levels at initial diagnosis were higher in three dead patients than in those alive (2,290 vs. 186.62 copies/µl).ConclusionWhen EBV DNA levels were high, patients showed severe skin lesions and when EBV DNA levels were low, skin lesions tended to improve. Thus, patients with high EBV DNA levels showed an increased risk of severe skin lesions and disease progression.

Brown spider venom toxins: what are the functions of astacins, serine proteases, hyaluronidases, allergens, TCTP, serpins and knottins?

Accidents caused by the bites of brown spiders (Loxosceles) generate a clinical condition that often includes a threatening necrotic skin lesion near the bite site along with a remarkable inflammatory response. Systemic disorders such as hemolysis, thrombocytopenia, and acute renal failure may occur, but are much less frequent than the local damage. It is already known that phospholipases D, highly expressed toxins in Loxosceles venom, can induce most of these injuries. However, this spider venom has a great range of toxins that probably act synergistically to enhance toxicity. The other protein classes remain poorly explored due to the difficulty in obtaining sufficient amounts of them for a thorough investigation. They include astacins (metalloproteases), serine proteases, knottins, translationally controlled tumor proteins (TCTP), hyaluronidases, allergens and serpins. It has already been shown that some of them, according to their characteristics, may participate to some extent in the development of loxoscelism. In addition, all of these toxins present potential application in several areas. The present review article summarizes information regarding some functional aspects of the protein classes listed above, discusses the directions that could be taken to materialize a comprehensive investigation on each of these toxins as well as highlights the importance of exploring the full venom repertoire.