Necrotic Skin Lesions Research Articles

Mycotic Necrotizing Fasciitis of the Face: A Case Report and Review of Literature

Necrotizing fasciitis is a rare but potentially serious and fatal infection. It is a dermo-hypodermitis with necrosis of the superficial fascia, typically caused by Streptococcus pyogenes. However, rare cases of fungal necrotizing fasciitis have been reported. We report the case of a 65-year-old type II diabetic patient who developed necrotizing cellulitis of the right hemiface with homolateral orbito-palpebral extension. The initial management was based on drainage of purulent collections with resection of necrotic tissues associated with parenteral antibiotherapy without clinical improvement. Bacteriological sampling revealed the presence of yeast. The mycological examination was positive for Candida albicans resistant to fluconazole. Antifungal treatment with intravenous amphotericin B was initiated with good clinical progression and complete remission after 1 month. The aim of this paper is to highlight the importance of promptly considering this diagnosis and extending the initial assessment of necrotic skin lesions to include mycological examination to detect severe forms of cutaneous candidiasis.

Severe Antiphospholipid Syndrome in a Child with Chicken Pox: Clinical Case

Background. Antiphospholipid syndrome develops at autoimmune diseases, pregnancy, or genetic predisposition, and it is characterized by high risk of thrombosis in arterial, venous, and capillary vessels. This syndrome in children is rare, and necrotic skin lesions occur in the most extreme cases. Clinical case description. A child, 1 year old, with chicken pox has developed hemorrhagic rash on his back, swelling of the left shoulder and forearm on the 4th day of the disease. Medical treatment included acyclovir, ceftriaxone, sodium heparin. Aggravation of hemorrhagic rash over the body, spread of edema from the left shoulder to upper arm and neck, formation of flaccid bubble and necrosis locus (75 cm) on the outer upper third of the left shoulder were noted on the 5th-6th day. Increase in the levels of antibodies to 2-glycoprotein I (IgG — 48.9 U/ml, IgM — > 100 U/ml) and cardiolipin (IgM — 73.0 U/ml) was revealed. The diagnosis “antiphospholipid syndrome” was established. All necrotized tissues were removed on the 11th day, and the wound defect (86 cm) was subsequently covered by mesh skin grafts. The levels of antibodies (IgG + IgM) to 2-glycoprotein I remained high, 45.2 U/mL, 12 weeks after the onset of the disease. Thus, it has confirmed the development of antiphospholipid syndrome. The child continued treatment with warfarin (3.75 mg/day) with INR control. Conclusion. Hemorrhagic skin lesions in children with infectious diseases requires laboratory diagnostics of antiphospholipid syndrome, early prescription of anticoagulant and antiplatelet therapy, and surgical support.

#760 Monogenic lupus with ANCA associated vasculitis-phenotype and ANCA positivity due to DNASE1L3 mutations: case report and review of the literature

Abstract Background and Aims Monogenic systemic lupus erythematosus (SLE) accounts for 7-10% of cases of early-onset SLE. DNASE1L3 is an extracellular nuclease that digests chromatin released from apoptotic cells and its deficiency, enhance autoantibody production and type I interferon responses and cause different autosomal recessive phenotypes including SLE and hypocomplementemic urticarial vasculitis syndrome (HUVS) [1]. In some cases patients can have a mixed SLE-AAV phenotype. Kidney involvement in patients with DNASE1L3 mutations is poorly characterised. Method We present the case report of a 7-years-old boy with monogenic SLE due to DNASE1L3 mutations who developed severe glomerulonephritis leading to kidney failure. Results The patient had a history of urticaria and arthralgia and presented with fever, haemolytic anaemia, lymphadenopathy, hepato-splenomegaly, erythematous- macular and necrotic skin lesions, and interstitial lung disease. He also had acute kidney injury (serum creatinine 5.4 mg/dL), nephrotic- range proteinuria (3.9 g/24 h) and microhaematuria. Immunological tests revealed low C3 and C4, positive anti-nuclear antibody (ANA) and myeloperoxidase-antineutrophil cytoplasmic antibodies (MPO-ANCA), with negativity of anti-extractable nuclear antigen antibodies (anti-ENA) and anti-double stranded DNA (anti-dsDNA). Kidney biopsy showed pauci-immune (mesangial C3+ and IgG+) necrotising crescentic glomerulonephritis. The patient proved refractory to standard immunosuppression with cyclophosphamide and steroids. Two years later, due to renal function decline, a new kidney biopsy was performed and showed diffuse necrotising glomerulonephritis with endo- and extra-capillary proliferation; intense mesangial and subendothelial full-house deposits were evident on immunofluorescence. The patient did not respond to other lines of immunosuppression (mycophenolate mofetil, tacrolimus, azathioprine, rituximab), including the JAK inhibitor ruxolitinib. Kidney failure progressed to end stage at the age of 15 years, when the patient began haemodialysis. The kidney presentation, immunological profile and the first kidney biopsy led to diagnosis of AAV. However, the diagnosis was questioned due to the refractory course, the systemic clinical presentation and the second kidney histology (consistent with lupus nephritis). High interferon signature was detected and in the suspicion of a monogenic lupus nephritis Whole Exome Sequencing was performed and revealed homozygous DNASE1L3 variants (c.290_291delCA p.T97Ifs*2); thus, a final diagnosis of DNASE1L3 monogenic SLE was made. DNASE1L3 serum levels were normal but the DNAse enzymatic activity was low. Conclusion Renal involvement is one of the most frequent manifestations of DNASE1L3-related lupus; in the literature 32 cases of DNASE1L3-associated lupus nephritis are described. ANCA are positive in about 55% of these cases and are associated with a mixed lupus-AAV phenotype. All cases are characterized by resistance to common immunosuppressors and poor renal prognosis [2]. DNASE1L3 regulates neutrophil extracellular trap (NET) clearance and when this function is reduced the permanence of NETs induces endothelial damage and autoantibody formation. This pathogenic pathway is shared both by SLE and by AAV. There is no association between specific mutations and antibody positivity or clinical manifestations.

Spider bite presenting as fever, macrophage activation syndrome and a skin ulcer

Introduction: Fever of unknown origin (FUO) refers to a condition of prolonged increased body temperature, without identified causes. The most common cause of FUO worldwide are infections; arthropod bites (loxoscelism) should be considered in view of the spread of the fiddleback spider. Loxoscelism can present in a cutaneous form (a necrotic cutaneous ulcer) or in a systemic form with fever, haemolytic anaemia, rhabdomyolysis and, rarely, macrophage activation syndrome (MAS). For this suspicion, it is important to have actually seen the spider. Case description: A 71-year-old man was admitted to our department because of intermittent fever, arthralgia and a necrotic skin lesion on his right forearm that appeared after gardening. Laboratory tests were negative for infectious diseases, and several courses of antibiotics were administered empirically without clinical benefit. Whole-body computed tomography showed multiple colliquative lymphadenomegalies, the largest one in the right axilla, presumably of reactive significance. A shave biopsy of the necrotic lesion was performed: culture tests were negative and histological examination showed non-specific necrotic material, so a second skin and lymph node biopsy was performed. The patient developed MAS for which he received corticosteroid therapy with clinical/laboratory benefit. Cutaneous and systemic loxoscelism complicated by MAS was diagnosed. Subsequently, the second biopsy revealed morphological and immunophenotypic findings consistent with primary cutaneous anaplastic large cell lymphoma (PC-ALCL). Conclusions: Skin lesions and lymphadenomegalies of unknown origin should always be biopsied. It is very common to get indeterminate results, but this does not justify not repeating the procedure to avoid misdiagnosis.

Unique characteristics of anti-MDA-5 associated dermatomyositis in Southern California with a large Hispanic population

ObjectivesThere is little to no data about the presentation and clinical course of anti-melanoma differentiation-associated gene-5 antibody (anti-MDA-5) dermatomyositis in a primarily U.S. Hispanic population. We describe the clinical course of anti-MDA-5 dermatomyositis in our majority Hispanic population. MethodsThis is a multicenter, retrospective case series of anti-MDA-5 dermatomyositis. Patients diagnosed with anti-MDA-5 dermatomyositis from June 2015 to March 2023 at four medical centers in Los Angeles, California, were included. Demographics and clinical characteristics were obtained. Descriptive statistics, Pearson's chi-squared, Fisher's exact, Wilcoxon rank sum, and Kruskal-Wallis tests were performed as applicable. ResultsThirty anti-MDA-5 dermatomyositis patients were included. Twenty-two (73 %) were Hispanic. Twenty-one patients (70 %) were female, with a median age of 40.5 years. Hispanic patients were diagnosed with anti-MDA-5 dermatomyositis at a younger age than non-Hispanic patients (p = 0.025). Inflammatory arthritis was prominent; more males were affected than females (p = 0.027). Thirteen patients (43 %) were amyopathic. Twenty-five patients (83.3 %) had evidence of interstitial lung disease (ILD), and a higher ferritin level was associated with ILD (p = 0.049). There were six deaths (20 %); five (17 %) were ascribed to rapidly progressive ILD. ConclusionILD was the most common presentation of anti-MDA-5 dermatomyositis in our cohort and was associated with higher ferritin levels. Hispanic patients had a younger age of diagnosis than non-Hispanic patients. Necrotic skin lesions and inflammatory arthritis were frequently seen. This is the first study looking at clinical phenotypes and outcomes of anti-MDA-5 dermatomyositis in a primarily Hispanic U.S. population. Future studies are needed to better understand the clinical manifestations (to promptly recognize and treat) of this population of anti-MDA-5 dermatomyositis.

In silico Identification of Putative Drug Targets in Mycobacterium ulcerans Virulence Proteins

Background: Buruli ulcer (BU), caused by Mycobacterium ulcerans is a neglected tropical disease characterized by necrotic skin lesions. Antibiotic therapy and excision of the lesions are the treatments for this chronic disease. During the management of the disease, the emergence of drug resistance in these bacilli is a major challenge. Therefore, there is a need to identify new drug targets against this important pathogen. Objective: The study aimed to investigate novel drug targets exploring virulence factors of M. ulcerans by in silico analysis. Methods: Virulence proteins encoded by the chromosome of Mycobacterium ulcerans strain Agy99 were retrieved and analyzed for their cellular localization, human non-homology and essentiality. Further, proteins were analyzed for their physio-chemical characterization, drug resistance analysis, protein interaction analysis, metabolic pathway prediction, and druggability prediction by various databases and online software to find their suitability as drug targets. The structure of the predicted drug targets was also modeled and validated. Among three predicted drug targets, MUL_4536 was subjected to molecular docking with some known inhibitor compounds also. Receptor-ligand complex with the highest binding energy was selected for molecular dynamic (MD) simulation to determine the structural stability of the complex. Results: Three virulence proteins MUL_4536, MUL_3640, and MUL_2329 encoding enzymes iso-citrate lyase, lysine-N-oxygenase, pup-protein ligase, respectively were predicted as a drug target against M. ulcerans. Isocitrate lyase has been identified as a potential drug target in many other mycobacterial and non-mycobacterial diseases. Lysine-N-oxygenase is the enzyme of mycobactin biosynthesis pathway and pup-protein ligase is associated with the pup-proteasome system. Proteins of these pathways have been studied as attractive drug targets in previous research works, which further support our predictions. Conclusion: Our computational analysis predicted new drug targets, which could be used to design drugs against M. ulcerans. However, these predicted proteins require further experimental validation for their potential use as drug targets.

SAT214 A Rare Case Of Biopsy-proven Non-uremic Calciphylaxis In A Patient With Secondary Hyperparathyroidism

Abstract Disclosure: U.A. Ogar: None. A.G. Olafimihan: None. I. Asemota: None. E. Krishnaraju: None. A. Okafor: None. Introduction: Calciphylaxis, also known as calcific uremic arteriolopathy, is a rare, lethal, metastatic calcification involving cutaneous microvasculature that presents as painful necrotic skin lesions. It typically occurs in patients with end-stage kidney disease (ESKD), renal transplant, or acute kidney injury requiring renal replacement therapy. Calciphylaxis occurring without these comorbidities is termed non-uremic calciphylaxis (NUC), which is rarer. NUC’s etiology is unclear but it has been associated with hyperparathyroidism, malignancies, alcohol liver disease, and connective tissue disorders. There are only a few reported cases of biopsy-proven NUC in patients with secondary hyperparathyroidism, as in our patient. Clinical Case: A 63-year-old female with a history of COPD on home oxygen therapy, smoking, and alcohol use disorder presented with a four-day history of severe, painful, purplish left thigh rash. She had no recent trauma or insect bite. Her physical exam showed a large (6x10 cm), tender, distal anterior left thigh bruise. Laboratory findings were significant for elevated creatine of 4.3 mg/dL from a normal baseline creatinine (0.6 mg/dL), normal serum corrected calcium (10.1 mg/dL) and elevated phosphate (4.7mg/dL). Three days following her admission, the skin lesion had progressed into multiple brown coalescing bullae with central ulceration, collarette, surrounding erythema, warmth, and induration. Due to concern for possible skin and soft tissue infection, empiric vancomycin therapy was started. However, the overall clinical picture was not convincing of an infection, necessitating consultation with the Dermatology team. A skin biopsy was recommended, and this was diagnostic of calciphylaxis. Further testing revealed hyperparathyroidism (202pg/ml), low 25 hydroxy Vitamin D (12ng/ml), and negative autoimmune and thrombophilia workup. Her treatment plan included wound care with debridement, analgesia, and interdisciplinary clinic follow-up. During outpatient follow-up, her wound was seen to be slowly healing with daily wound dressing, and her elevated serum creatinine had resolved. Conclusion: NUC has a high mortality rate (52%) and requires a high index of clinical suspicion to ensure prompt diagnosis and initiation of treatment. Differential diagnoses include atherosclerotic vascular disease, vasculitis, hypercoagulable disorders, and cellulitis as in our patient. Skin biopsy is diagnostic. Aggressive wound care and analgesia are pivotal to treatment, in addition to addressing underlying precipitating conditions. Other treatment options like sodium thiosulphate exist but with uncertain outcomes. Efforts geared at definitive therapeutic modalities are needed. Presentation: Saturday, June 17, 2023

Calciphylaxis in a patient with hypoparathyroidism and MEN-1 syndrome.

Calciphylaxis is a rare disorder characterised by the development of painful necrotic skin lesions. Occlusion of cutaneous arterioles due to ectopic calcification leads to potentially life-threatening widespread skin loss. Most cases occur in patients with chronic renal disease, which leads to dysregulation of calcium and phosphate homeostasis. Only a handful of case reports exist describing calciphylaxis occurring in patients without chronic renal disease but with hypoparathyroidism. We report on a unique case of a 53-year-old man with multiple endocrine neoplasia type 1 syndrome and acquired hypoparathyroidism due to total parathyroidectomy who went on to develop calciphylaxis following cardiac surgery. Calciphylaxis most commonly occurs in the context of chronic renal disease but can rarely occur in its absence as a consequence of calcium and phosphate dysregulation. Patients who develop necrotic skin lesions in the presence of hypoparathyroidism require an urgent dermatological opinion. Mortality from calciphylaxis is high, with the majority of deaths occurring secondary to sepsis. Management of calciphylaxis requires a multidisciplinary team approach to manage wound healing, infections and pain. Recovery with full rehabilitation from calciphylaxis can take months to years.

Presumptive hepatogenous photosensitization in beef cattle winter grazing a cover crop containing Brassica spp. turnips.

Over a period of ~2 wk, 5 adult beef cows developed severe necrotizing skin lesions on the face and neck shortly after being moved to a field with a cover crop of Brassica spp. turnips. We describe here the clinical signs, hematology, and serum chemistry results, as well as gross and histopathologic findings, from this outbreak. We made a presumptive diagnosis of Brassica-associated liver disease (BALD) based on the similarities in the history and diagnostic findings observed with previously reported cases of BALD from elsewhere in the world. BALD has not been reported previously in cattle in North America, to our knowledge, despite the increasing usage of cover crops to improve soil conditions and provide forage for livestock. After the presumptive diagnosis of BALD was made, the cattle were removed from the turnip field and no additional cases were noted by the producer. BALD is well known in other parts of the world, and veterinarians and diagnosticians should be aware of this condition given that the usage of cover crops is likely to continue to increase.

The New Stealth Drug on the Street: A Narrative Review of Xylazine as a Street Drug.

Xylazine is an alpha-adrenergic receptor agonist approved for use only in animals with a prescription from a veterinarian. It is a powerful sedative that is slowly infiltrating the recreational street drug scene and is often used by polysubstance abusers. Known as "tranq," it can be fatal, and xylazine-induced toxicity cannot be reversed with naloxone or nalmefene. Due to its vasoconstrictive effects, chronic use of xylazine is associated with necrotic skin lesions and general deterioration of health. Since xylazine is not approved for human use and is not scheduled as a controlled substance, there are no human studies to provide evidence of drug-drug interactions, lethal doses, or reversal protocols. Xylazine is available online without a prescription. Street drug users may take xylazine knowingly or unknowingly, as it is often combined with other illicit substances such as fentanyl. There are no rapid tests for xylazine, although there are specialty tests that can be ordered. Xylazine represents a major threat to street drug users and another challenge to emergency healthcare workers, first responders, and others who care for those who have taken this "new" street drug.

Diffuse alveolar hemorrhage in a chronically hemodialyzed patient with progressive necrotic skin lesions as a manifestation of calciphylaxis.

Diffuse alveolar hemorrhage in a chronically hemodialyzed patient with progressive necrotic skin lesions as a manifestation of calciphylaxis.

Memory B-cells are enriched in the blood of patients with acute Buruli ulcer disease: a prospective observational study

BackgroundBuruli ulcer disease (BUD) caused by Mycobacterium (M.) ulcerans is characterized by necrotic skin lesions. As for other mycobacterial infections, e.g., tuberculosis, the immune response is important for host protection. B-cells may play a role in antimycobacterial immunity but studies characterizing the B-cell repertoire and memory generation in BUD and during the course of treatment are scarce.MethodsWe investigated the adaptive immune cell repertoire in children with BUD and healthy matched controls by flow cytometry. Analyses prior to treatment, also in a study group of patients with tuberculosis, as well as three time points during BUD treatment (i.e., week 8, 16, and 32) were performed. In addition, BUD disease severity as well as treatment response were analysed for association with B-cell repertoire differences.ResultsChildren with BUD had comparable total B- and T-cell proportions but differed largely in B-cell subsets. Memory B-cell (B mem) proportions were higher in children with BUD whereas regulatory B-cell (B reg) proportions were lower as compared to healthy controls and tuberculosis patients. Lower naïve (B naïve) and higher transitional B-cell (B trans) proportions characterized children with BUD in comparison with tuberculosis patients. Under treatment, B mem proportions decreased significantly whereas proportions of B reg and B naive increased concomitantly in children with BUD. Also, we found significant correlation between lesion size and B mem as well as B reg. However, we did not detect associations between treatment efficacy and B-cell proportions.ConclusionsThese results suggest a role of B-cell subsets in the immune response against M. ulcerans. Furthermore, changes in B-cell subset proportions may be used as markers for treatment monitoring in BUD.

From Bacterial Toxin to Therapeutic Agent: The Unexpected Fate of Mycolactone

“Recognizing a surprising fact is the first step towards discovery.” This famous quote from Louis Pasteur is particularly appropriate to describe what led us to study mycolactone, a lipid toxin produced by the human pathogen Mycobacterium ulcerans. M. ulcerans is the causative agent of Buruli ulcer, a neglected tropical disease manifesting as chronic, necrotic skin lesions with a “surprising” lack of inflammation and pain. Decades after its first description, mycolactone has become much more than a mycobacterial toxin. This uniquely potent inhibitor of the mammalian translocon (Sec61) helped reveal the central importance of Sec61 activity for immune cell functions, the spread of viral particles and, unexpectedly, the viability of certain cancer cells. We report in this review the main discoveries that marked our research into mycolactone, and the medical perspectives they opened up. The story of mycolactone is not over and the applications of Sec61 inhibition may go well beyond immunomodulation, viral infections, and oncology.

Mpox and HIV: a Narrative Review.

We reviewed the available literature on mpox in People with HIV (PWH). We highlight special considerations of mpox infection related to epidemiology, clinical presentation, diagnostic and treatment considerations, prevention, and public health messaging in PWH. During the 2022 mpox outbreak, PWH were disproportionally impacted worldwide. Recent reports suggest that the disease presentation, management, and prognosis of these patients, especially those with advanced HIV disease, can widely differ from those without HIV-associated immunodeficiency. Mpox can often be mild and resolve on its own in PWH with controlled viremia and higher CD4 counts. However, it can be severe, with necrotic skin lesions and protracted healing; anogenital, rectal, and other mucosal lesions; and disseminated organ systems involvement. Higher rates of healthcare utilization are seen in PWH. Supportive, symptomatic care and single or combination mpox-directed antiviral drugs are commonly used in PWH with severe mpox disease. Data from randomized clinical control trials on the efficacy of therapeutic and preventive tools against mpox among PWH are needed to better guide clinical decisions.

A case of occupational transmission of mpox.

Between May 2022 and January 2023, a global mpox outbreak affected more than 84,000 patients across all continents. Transmission of mpox occurs through large respiratory droplets and direct contact with skin lesions. We present the case of a 31-year-old previously healthy male with mpox-Infection following occupational exposure to mpox from a needle stick injury with a sterile needle through a contaminated glove. The patient presented with a three-day history of fever, malaise, and an increasing erythema and swelling of one fingertip. The patient works as a medical doctor with regular exposure to patients infected with mpox. Mpox-PCR from a swab of the lesion and an oro-pharyngeal swab were positive. The lesion on his finger evolved into a necrotic skin lesion finally healing, leaving a scar. He did not develop any secondary pox on his skin and recovered fully. Only a minority of patients with mpox infection develop illness with pronounced local complications as in this case. Mpox can potentially be transmitted in an occupational context. Medical personnel should be informed about this possible route of transmission.

Successful treatment of pyoderma gangrenosum in a patient winh ulcerative colitis and COVID-19 infection: case report

Pyoderma gangrenosum is a rare inflammatory neutrophilic dermatosis, which causes ulceration of the skin. The condition is commonly associated with underlying systemic disorders such as inflammatory bowel disease, arthritis, and hematological disorders. Herein, we describe the case of a familiar association between pyoderma gangrenosum and ulcerative colitis complicated by the newly COVID-19 infection.
 It is of particular clinical interest to address pyoderma gangrenosum lesions with concurrent treatment of associated disorders that may have influence on the course of the ulcer. Moreover, the therapy should cover as many diseases as possible while not being excessive to minimize possible side effects.
 Thus, the selection of treatment that spans mutual pathophysiological features of all comorbidities represents the best option to make when handling pyoderma gangrenosum patients.
 We present a case of the development of gangrenous pyoderma against the background of ulcerative colitis complicated by the new coronavirus infection COVID-19, which will raise awareness of gangrenous pyoderma as a relatively rare cause of ulcerative necrotic skin lesions, which can easily be confused with an infectious process.
 Of particular clinical importance in the conditions of the COVID-19 pandemic is the correct treatment of gangrenous pyoderma. Only an integrated approach can give a positive result from the therapy.

Haematological and Biochemical Anomalies in Catfish, Clarias batrachus due to Cutaneous Ulcerations

The present study was carried out to investigate the haematological and biochemical parameters in healthy and ulcerated Catfish, Clarias batrachus. The haemorrhagic necrotic skin lesions in ulcerated fishes showed significant reduction (P<0.01) in RBC, haemoglobin, haematocrit (PCV) eosinophils and lymphocytes. The derived erythrocyte indices, namely, the MCV, MCH and MCHC of ulcerated fishes were also significantly decreased (P < 0.05) from those of normal fishes. Whereas, the total leucocyte count (TLC), neutrophils, monocytes and ESR were significantly increased (P<0.01 and P<0.05) in infected fishes. The biochemical analysis showed a significant reduction (P<0.01) in bilirubin content, whereas the blood glucose, SGOT and SGPT were significantly increased (P<0.01).

A Case of Cutaneous Vasculitis in the Setting of Systemic Lupus Erythematosus and Cocaine Use.

Cocaine, one of most prevalent illicit substances in the United States, affects a multitude of organ systems and precedes numerous negative health outcomes. Many of the consequences of cocaine are linked to induction of vasoconstriction. For this reason, cocaine users are placed at considerable risk of ischemic stroke, myocardial infarction, and cardiac arrhythmias. Furthermore, a prominent contaminant, levamisole, has been widely implicated in predisposing individuals to developing or exacerbating cutaneous vasculitides. This report details a 31-year-old woman with acute, localized necrotic skin lesions after cocaine use. Her clinical picture was complicated by a 17-year history of systemic lupus erythematosus (SLE) and Raynaud's phenomenon. This case examines the challenge of forming a differential diagnosis, initiating an appropriate workup, and interpreting serologic-based and immunologic-based studies to differentiate between SLE and drug-based etiologies of skin necrosis. Finally, we discuss appropriate treatment plans to mitigate symptoms and reduce future instances of drug-induced vasculitis.

563: IODODERMA WITH RESPIRATORY COMPROMISE TREATED WITH HEMODIALYSIS

Introduction: Iododerma is a rare, delayed type IV hypersensitivity reaction due to iodine deposition within the skin. With only a few published case reports, iododerma as a syndrome has been associated with exposure to iodine-containing materials such as contrast media, amiodarone, or povidone-iodine solution, with most cases involving lesions along the face and upper extremities (1). Diagnosis of iododerma is difficult, as lesions can raise concern for infection or vasculitis. We highlight a case of iododerma leading to airway compromise which was successfully treated with hemodialysis. Description: A 51 yo F with a PMH of diabetes mellitus, CKD stage IV, and diastolic heart failure presented with symptomatic anemia and underwent workup that included a CT abdomen and pelvis with oral contrast. She returned nine days later with evolving necrotic skin lesions within the perioral and periorbital areas. She developed facial and supraglottic mucosal edema with extensively sloughing bullous lesions and required intubation. A skin biopsy demonstrated neutrophilic infiltrates with a cryptococcoid appearance consistent with neutrophilic dermatosis. Urine and serum iodine were significantly elevated (15143.4 and 10822.5 respectively), consistent with a diagnosis of iododerma. She was started on high dose corticosteroids and initiated on intermittent hemodialysis to assist with clearance of iodine. Following three sessions of hemodialysis, patient had a significant clinical improvement and reduction in iodine levels with successful extubation on hospital day 11. Discussion: Iododerma is largely a diagnosis of exclusion but should be considered in patients with suggestive skin lesions and recent exposure to iodine-containing materials, particularly patients with underlying renal dysfunction. Diagnosis is typically made with a skin biopsy demonstrating neutrophilic infiltrates with structures that mimic Cryptococcus, in conjunction with elevated serum and urine iodine levels (2). While treatment with steroids is typical, we highlight a case where hemodialysis led to rapid clinical improvement in a very severe case of iododerma, suggesting utility in the ICU setting. 1. Tasker et al., 2019. Clin Exp Dermatol, 44: 844-860. 2. Runge et al, 2020. JAAD Case Reports, 6 (4): 319-322.

Multiple necrotizing skin lesions due to glatiramer asetate injection

Nicolau’s syndrome due to glatiramer acetate (GA) injection has been rarely reported. We report a 35-year-old woman with multiple sclerosis who presented with two necrotizing skin lesions due to consecutive subcutaneous GA injection. The patient was diagnosed with Nicolau’s syndrome and treated with wound care. The lesions regressed slowly with a mild scarring. We discontinued GA treatment because of the recurrence risk of skin lesions. We think the syndrome has a good prognosis with conservative treatment; however, discontinuation of GA may be necessary especially in case of multiple skin lesions.