Nonhealing Skin Lesions Research Articles

Hexasodium fytate for the treatment of calciphylaxis: a randomised, double-blind, phase 3, placebo-controlled trial with an open-label extension

In the CALCIPHYX trial, we investigated hexasodium fytate, an inhibitor of vascular calcification, for the treatment of calcific uraemic arteriolopathy (calciphylaxis), a rare condition characterised by painful, non-healing skin lesions. In this international, phase 3, randomised, double-blind, placebo-controlled trial, adults with an ulcerated calciphylaxis lesion and pain visual analogue scale (VAS) score ≥50/100 were randomised 1:1 to hexasodium fytate 7mg/kg or placebo intravenously during maintenance haemodialysis. Primary efficacy outcomes were an 8-item modification of the Bates-Jensen Wound Assessment Tool (BWAT-CUA) and Pain VAS in the intention-to-treat population. ClinicalTrials.gov number: NCT04195906. Overall, 34/37 patients randomised to hexasodium fytate and 26/34 patients randomised to placebo completed the 12-week randomised treatment period. At Week 12, both groups (hexasodium fytate versus placebo) showed similar improvements in BWAT-CUA (mean [standard deviation (SD)],-5.3 [5.2] versus-6.0 [6.2]; least squares mean difference, 0.3 [96% confidence interval (CI):-2.5, 3.0]; p=0.88) and Pain VAS (mean [SD],-19.5 [26.9] versus-32.2 [38.5]; least squares mean difference, 11.5 [96% CI:-4.8, 27.8]; p=0.15). One patient randomised to placebo briefly received hexasodium fytate in error. Serious adverse events through Week 12 included: calciphylaxis-related events leading to hospitalisation (2/38 [5%] versus 11/33 [33%]) and death (1/38 [3%] versus 5/33 [15%]). During the subsequent 12 weeks of open-label hexasodium fytate and 4 weeks of follow-up, there were no additional calciphylaxis-related events leading to hospitalisation. Over the course of the entire trial, deaths were 2/38 [5%] for the hexasodium fytate group and 7/33 [21%] for the placebo group. In patients with calciphylaxis, BWAT-CUA and Pain VAS improved similarly in hexasodium fytate- and placebo-treated patients; over the course of the entire trial, there were fewer deaths and calciphylaxis-related events leading to hospitalisation in the hexasodium fytate group. Funded by Sanifit, a CSL Vifor company.

#2435 Calciphylaxis: patient demographics, risk factors and outcomes in a single regional centre in New Zealand

Abstract Background and Aims Calciphylaxis, a condition associated with microvascular calcification and subsequent formation of non-healing tender skin lesions, has previously been estimated to affect only approximately 1% of patients with ESRD each year. However, clinicians practicing in a regional renal unit in the North Island of New Zealand have noted an increase in the frequency of clinical diagnoses of this condition over recent years. The aim of this review was to analyze patient demographics and risk factors and attempt to identify any correlation with subsequent outcomes. Method A cross sectional retrospective review of dialysis patients from Palmerston North Hospital's Renal Unit who were found to have diagnoses of calciphylaxis, was performed. The following factors were assessed: gender, ethnicity, smoking status, diabetes, obesity, hypertension, dialysis modality, prescription of phosphate binders, vitamin D analogues, and sodium thiosulphate (STS). We included patients with both histologically proven calciphylaxis and clinical diagnosis only. Levels of serum PTH, calcium and phosphate at the time of diagnosis were reviewed, though only PTH levels were included in the final analysis. Results A total of nineteen patients were identified having calciphylaxis as a diagnosis in the period studied. Findings were limited due to the small patient cohort size, but of those identified and reviewed some commonalities were found. Included were 9 NZ European people and 8 NZ Māori people. There were 8 females. One patient was a current smoker at time of diagnosis and five were documented as ex-smokers. Fourteen patients (74%) had type 2 diabetes mellitus and hypertension. Twelve patients (63%) were obese. Eighteen patients (95%) had hyperparathyroidism. Warfarin use was seen in 10 of the patients studied (52%) and twelve (63%) had used phosphate binders. Nine patients (47%) were diagnosed in the period between 2011 and 2021, with the remaining ten (53%) diagnoses occurring in 2022 or 2023. The majority (90%) were treated with STS, however 84% died. Dialysis modality at time of diagnosis and throughout disease span was also reviewed. Eight patients (42%) used only haemodialysis (HD), six patients (32%) used both modalities and five patients (26%) used only peritoneal dialysis. The majority (63%) of patients were on haemodialysis at time of diagnosis. Conclusion Calciphylaxis appears to be increasing dramatically in the single center studied in this review. Positive correlations were identified between high levels of PTH, obesity, hypertension, type 2 diabetes, and use of warfarin. Unfortunately, due to small case numbers, and poor historical documentation, further conclusions could not be drawn easily. A further RCT would be required to investigate the efficacy of STS as a treatment for calciphylaxis.

Diagnostic challenges in cutaneous leishmaniasis due to atypical Leishmania infantum: pathologists' insights from re-emergence zones.

Leishmaniasis, a parasitic infection affecting both humans and animals, is increasingly spreading across Mediterranean and European regions, largely driven by human migration and environmental changes. In countries like Türkiye and across Europe, which have seen large influxes of migrants, the incidence of cutaneous leishmaniasis (CL) is rising, with cases now appearing in cities where the disease was previously undocumented. In these previously non-endemic areas, physicians unfamiliar with the characteristic lesions may misdiagnose CL, particularly in cases with only cutaneous manifestations. This study aims to evaluate the impact of re-emerging CL on the routine diagnostic practices of pathologists in Türkiye, by retrospectively reviewing cases. We conducted a retrospective analysis of CL cases diagnosed between 2013 and 2022 at a single pathology center in Türkiye, covering multiple provinces. Twelve cases of CL were identified and analyzed based on clinical presentation, pre-diagnosis, histopathological findings, and molecular diagnostics. DNA extraction and PCR were performed on paraffin-embedded tissue samples to identify the Leishmania species involved. Out of the twelve CL cases reviewed, seven exhibited morphological findings strongly suggestive of CL (MFSS of CL), warranting further microbiological evaluation. All patients presented with non-healing skin lesions characterized by central ulceration, crater-like formations, or papulonodular lesions. Notably, CL was included in the clinical pre-diagnosis in only 58.3% of cases, while it was not considered in the remaining 41.7% of cases. Clinicians initially pre-diagnosed skin tumors in six cases (50%), four of which led to wide surgical excision. Histopathological examination in all cases revealed chronic or mixed (acute/chronic) inflammation, predominantly rich in histiocytes. To further investigate the role of Leishmania species in the pre-diagnosis, DNA extraction and PCR were performed on paraffin-embedded tissue samples, identifying L. infantum as the causative agent in 10 cases and L. major in two cases. Notably, L. infantum was the causative agent in all five cases initially misdiagnosed as skin tumors, which were also associated with a granulomatous type of chronic inflammation.

Niet-genezende huidletsels van de borst

Non-healing skin lesions in the right mammary region Although almost all dermatological conditions are visible, some patients wait a long time to consult a dermatologist. Nevertheless, an early diagnosis is important for the treatment and prognosis in case of cutaneous cancers. A 39-year-old man with skin lesions on his right chest, present for 3 years and slowly growing over time, consulted the dermatologist. The anatomopathological examination showed a diffuse-type primary cutaneous follicular B-cell non-Hodgkin lymphoma. Staging revealed a primary cutaneous lymphoma. After deliberation in a multidisciplinary oncologic consultation, radiotherapy was started. Cutaneous lymphomas are often difficult to diagnose because of their non-specific and variable clinical presentation. Skin biopsies should be performed when patients present with atypical cutaneous lesions. In case of cutaneous B-cell lymphomas, early diagnosis is important to detect and treat an underlying systemic or aggressive B-cell lymphoma. A multidisciplinary management team including dermatologists, pathologists, hematologists and radiation oncologists is necessary.

An In Vitro Study on Sonodynamic Therapy of Leishmania tropica Using Curcumin

Leishmaniasis is an infectious disease that is transmitted by Phlebotomus, 400 thousand new cases appearing every year, and approximately 350 million people are at risk, and accepted by the World Health Organization as one of the six important tropical diseases. Cutaneous leishmaniasis is a disease that occurs on exposed areas of the body and is characterized by long-term non-healing skin lesions. Although the treatment methods applied today vary according to the clinical picture of the patient, the immune system of the person and the causative agent Leishmania species, there is still no standard treatment scheme that has few side effects and can be used in the treatment of leishmaniasis. Therefore, alternative treatment methods with less side effects are being tried. Sonodynamic therapy (SDT) has also emerged as an active antimicrobial research area in recent years. SDT, a new modality for antibacterial therapy, aims to increase antibacterial effects with the simultaneous combination of low-intensity ultrasound and sonosensitizer. There is no information in the literature about the effect of SDT on parasites. In this study, it was aimed to demontrate the anti-leishmanial effect and possible mechanisms of curcumin mediated SDT on L.tropica promastigotes in vitro. Parasites were incubated with 0.25, 1.0, 4.0 and 15.6 micromolar (μM) of curcumin for one hour and subjected to 1 MHz frequency, 50% duty cycle and 3 W/cm2 intensity ultrasound irradiation. XTT assay was used to evaluate the viability of the cells and morphological changes were analyzed by Giemsa staining. Flow cytometry was used to quantify the fluorescence emitted by intracellular reactive oxygen species (ROS) signal, JC-1, cell cycle, Annexin V/PI staining reagents. With the combination of curcumin (15.6 μM) and ultrasound (3 W/cm2 intensity, seven minutes), L.tropica promastigote viability was found to be significantly decreased compared to the control group. Giemsa staining results showed that 15.6 μM curcumin mediated SDT induced several morphological alterations in L.tropica promastigotes typical for apoptosis. Late apoptosis was observed in 15.6 μM curcumin combined SDT treated parasites according to Annexin/PI staining. Besides, curcumin mediated SDT caused mitochondrial membrane potential (∆ᴪm) loss. Cell cycle analysis data indicated that curcumin based SDT caused an subG1 arrest in the cell cycle of L.tropica promastigotes. The generation of intracellular ROS detected by flow cytometry was increased in L.tropica promastigotes treated with curcumin mediated SDT. This study provided new data elucidating the molecular mechanism underlying the anti-leishmanial effect of curcumin mediated SDT. Curcumin mediated SDT has the potential to inactivate L.tropica promastigotes. However, further testing with amastigote or animal models is needed.

Centrin-deficient Leishmania mexicana confers protection against New World cutaneous leishmaniasis

Leishmaniasis is a neglected protozoan disease affecting over 12 million people globally with no approved vaccines for human use. New World cutaneous leishmaniasis (CL) caused by L. mexicana is characterized by the development of chronic non-healing skin lesions. Using the CRISPR/Cas9 technique, we have generated live attenuated centrin knockout L. mexicana (LmexCen−/−) parasites. Centrin is a cytoskeletal protein important for cellular division in eukaryotes and, in Leishmania, is required only for intracellular amastigote replication. We have investigated the safety and immunogenicity characteristics of LmexCen−/− parasites by evaluating their survival and the cytokine production in bone-marrow-derived macrophages (BMDMs) and dendritic cells (BMDCs) in vitro. Our data shows that LmexCen−/− amastigotes present a growth defect, which results in significantly lower parasitic burdens and increased protective cytokine production in infected BMDMs and BMDCs, compared to the wild type (WT) parasites. We have also determined the safety and efficacy of LmexCen−/− in vivo using experimental murine models of L. mexicana. We demonstrate that LmexCen−/− parasites are safe and do not cause lesions in susceptible mouse models. Immunization with LmexCen−/− is also efficacious against challenge with WT L. mexicana parasites in genetically different BALB/c and C57BL/6 mouse models. Vaccinated mice did not develop cutaneous lesions, displayed protective immunity, and showed significantly lower parasitic burdens at the infection site and draining lymph nodes compared to the control group. Overall, we demonstrate that LmexCen−/− parasites are safe and efficacious against New World cutaneous leishmaniasis in pre-clinical models.

Geographic distribution of Pythium insidiosum infections in the United States.

To describe the geographic distribution of infections caused by Pythium insidiosum in dogs, horses, and other animal species in the US. For the last 20 years, we have collected data from cases of pythiosis in 1,150 horses, 467 dogs, and other species (59) from various geographic locations in the US. Due to lost data (from 2006 to 2016), the selected cases include years 2000 to 2005 and 2016 to 2020. The selection of cases was based on infected host clinical features, serum samples demonstrating strong positive anti-P insidiosum IgG titers in serologic assays, and positive results on ≥ 1 of the following diagnostic modalities: microbial culture on 2% Sabouraud dextrose agar, histologic evaluation, PCR assay, and wet mount cytologic evaluation (with potassium hydroxide). Most confirmed P insidiosum infections were found in horses and dogs in the southeastern US. Interestingly, in Texas, no cases were found west of longitude 100°W. Few pythiosis cases were diagnosed in west-coast states. Equine cases were more often diagnosed during summer and fall months, but canine cases were more often diagnosed between September and February. Cases in other species were discovered in the same geographic areas as those in dogs and horses. To our knowledge, this is the first report providing the ecological distribution of P insidiosum infection in affected species in the US. Results of this study illustrated the importance of including P insidiosum in the differential diagnostic scheme of nonhealing skin lesions or intestinal granulomatous masses, particularly in dogs and horses inhabiting or having visited endemic areas.

Risk of Neurodegeneration in Patients with Morgellons Disease: A Focus on the Potential Risk of Developing Alzheimer’s

Morgellons disease is a distressing dermatologic condition that typically presents with multiple, non-healing skin lesions with filamentous protrusions. Initial presentation of the condition can often include various neurological symptoms with dermatologic symptoms. Common neurological symptoms include neuropathy, cognitive impairment, and dementia. Recent studies reveal that spirochetes are a causative agent of Morgellons disease. Chronic spirochete infection is strongly associated with neurodegeneration seen in dementia and Alzheimer’s disease. This paper will provide a brief overview of Morgellons and Alzheimer’s disease and will explore the possible risk of developing Alzheimer’s in Morgellons patients.

Highly resistant Mycobacterium abscessus subsp. abscessus infection in a Swiss cat

AbstractA 2‐year‐old European shorthair cat was presented with a nonhealing skin lesion on the right abdominal wall. Repeated surgical excision and antimicrobial treatment with cefovecin, clindamycin, and trimethoprim‐sulfamethoxazole did not lead to clinical improvement. Histopathology of the skin lesion showed pyogranulomatous dermatitis and panniculitis. Definitive diagnosis was made by mycobacterial culture and rpoB sequencing, revealing Mycobacterium abscessus subsp. abscessus. To the authors’ knowledge, this is the first report of Mycobacterium abscessus subsp. abscessus infection in a cat in Switzerland and the second case in Europe. The isolated strain carried a functional erm(41) gene that confers inducible macrolide resistance. Further phenotypic resistances to doxycycline, minocycline, and imipenem were detected, resulting in little chance of successful antimicrobial treatment. Mycobacterium abscessus subsp. abscessus is an emerging pathogen in human medicine and poses a non‐negligible zoonotic risk for the owners of the cat.

The Use of Umbilical Cord-derived Mesenchymal Stem Cells Seeded Fibrin Matrix in the Treatment of Stage IV Acute Graft-Versus-Host Disease Skin Lesions in Pediatric Hematopoietic Stem Cell Transplant Patients.

Mesenchymal stem cells (MSCs) have been used systemically or locally in many chronic and nonhealing skin lesions in recent years. In this study, umbilical cord-derived MSCs (UC-MSCs)-seeded fibrin matrix was used as a wound dressing in pediatric patients with stage 4 acute graft-versus-host disease (aGVHD)-induced desquamated skin lesions. This is the first study in which the UC-MSCs-seeded fibrin matrix was used as a wound dressing in aGVHD. A total of 14 times the MSCs-seeded fibrin matrix were applied to 9 patients as a wound dressing. On the seventh day, epithelialization and clinical response were evaluated. According to the size of the skin defect min: 1, max: 6 pieces were applied at a time. After 48 to 72 hours, it was observed that all of the MSCs-seeded fibrin matrixes adhered to the skin and the crustation started in 6 (43%) applications, whereas liquefaction was detected under all of them in 7 (50%) applications. Complete response was obtained in 6 applications (43%), partial response in 1 (7%), and no response in 7 applications (50%). This study showed that the MSCs-seeded fibrin matrix can be used effectively and safely in the matrix in the local treatment of aGVHD-induced skin wounds in pediatric patients.

Mycobacteriosis in a Zoo Population of Chinese Gliding Frogs (Rhacophorus dennysi) Due to Mycobacterium marinum

Mycobacteriosis was implicated in the deaths of eight Chinese gliding frogs (Rhacophorus dennysi) in a zoo population over a 3 yr period. Clinical signs included nonhealing skin lesions, cloacal prolapse, hind limb weakness, weight loss, and sudden death. Abnormalities on postmortem were proliferative or ulcerative skin lesions in four of eight, pneumonia in three of eight, and gall bladder empyema in two of eight cases. All eight clinical cases had multisystemic granulomas containing acid-fast bacilli. Tissues most commonly affected were lung (seven of eight), liver (six of eight), kidney (six of eight), spleen (five of eight), and heart (five of eight). The remaining eight clinically normal frogs in the population were euthanized: eight of eight had granulomatous lesions, with acid-fast bacilli in three of eight cases. A mycobacterial species was cultured from four of the clinical cases by the Public Health Ontario Laboratory and was initially misidentified as Mycobacterium tuberculosis complex by a commercial line-probe assay (GenoType Mycobacterium CM, Hain Lifesciences, Nehren, Germany). Further diagnostic testing using 16S rRNA gene sequencing ultimately identified the mycobacterial species as Mycobacterium marinum. The correct identification of mycobacterial species is essential in epidemiological investigations at zoological facilities, and in assessing health risks to staff and to other animals in the zoo population.

Transfection of Leishmania tropica with green fluorescent protein (gfp) gene and investigation of the in vitro drug effect

Cutaneous leishmaniasis (CL) is a parasitic disease transmitted by vector sand flies Phlebotomus and Lutzomyia. This disease is characterized by long time non-healing skin lesions, and caused by Leishmania species. CL is the most common infection in Eastern and Southeastern Anatolia in Turkey and L.tropica is known as the main agent of the disease. Number of cases is increasing in our country in time because of malnutrition, migration, travel, low socioeconomic level and ecological changes. For the treatment, the pentavalent antimonials are often used as intralesionally for many years, and it was reported that resistant cases have increased in recent years. New treatment methods and anti-Leishmanial activity of new agents have been investigated because of side effects, resistance development and toxic reactions of the present drugs. These studies are first carried out in vitro and afterwards with in vivo experimental animal models. Reporter gene technology has been used to investigate a variety of purposes like biological events in microorganisms and the efficacy and resistance of drugs in recent years. The major areas that green fluorescent protein (gfp) used are that they can be incorporated into different genes to determine the amount of expression of these genes in different organisms and can be used as markers in living cells. Especially gfp gene, which encodes the green fluorescent protein, is widely used nowadays. Gene-based assays have several advantages like being easy to follow-up, inexpensive and have improved biosecurity. The aim of the present study was to perform the transfection of L.tropica with "enhanced gfp (egfp)" and in vitro usefulness of gfp-transfectants as a drug screening model in comparison to the conventional methods. Promastigotes of L.tropica were transfected with p6.5/egfp by electroporation and selected for tunicamycin-resistance as previously described. L.tropica promastigotes transfected with gfp and in vitro effect of meglumine animoniate was assessed using different methods such as fluorescence microscopy, fluorometer and XTT (2,3-bis-(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxyanilide) assay. The use of gfp-transfected Leishmania strains was found more rapid and more sensitive by fluorescent microscopy and fluorometry than conventional assays for the evaluation of potential anti-leishmanial agents. Consequently, stable gfp-transfected Leishmania species will be used in vitro and in vivo for screening of anti-leishmanial drugs and vaccine development as well as for understanding the biology of the host-parasite interactions at the cellular level. As a result ot this study, gfp transfected model using a Turkish L.tropica isolate was established to be used in further studies.

Translating Observations From Leishmanization Into Non-Living Vaccines: The Potential of Dendritic Cell-Based Vaccination Strategies Against Leishmania.

Leishmaniasis is a health-threatening vector-borne disease in almost 90 different countries. While a prophylactic human vaccine is not yet available, the fact that recovery from leishmaniasis establishes lifelong immunity against secondary infection suggests that a vaccine is attainable. In the past, deliberate infection with virulent parasites, termed Leishmanization, was used as a live-vaccine against cutaneous leishmaniasis and effectively protected against vector-transmitted disease in endemic areas. However, the practice was discontinued due to major complications including non-healing skin lesions, exacerbation of skin diseases, and the potential impact of immunosuppression. Instead, tremendous effort has been made to develop killed, live attenuated, and non-living subunit formulations. Many of these formulations produce promising experimental results but have failed in field trials or against experimental challenge with infected sand flies. Recently, experimental models of leishmanization have unraveled the critical role of parasite persistence in maintaining the circulating CD4+ effector T cells responsible for mitigating the inflammatory response early after sand fly challenge and mediating protective immunity. Here, we put forward the notion that for effective vaccine design (especially non-living vaccines), the role of antigen persistence and pre-existing effector CD4+ T cells should be taken into consideration. We propose that dendritic cell-based vaccination strategies warrant greater attention because of their potential to act as long-term antigen depots, thereby emulating this critical requirement of naturally acquired protective immunity against infected sand fly challenge.

Synthesis and Evaluation of Biological Activity of Antimicrobial--Pro-Proliferative Peptide Conjugates.

Skin represents the largest organ of the human body and plays a crucial role in its protection from the negative impact of the outside environment, maintains its homeostasis, enables sensory interaction and thermoregulation. The traumatized skin tissue undergoes several phenotype switches due to progressive reoxygenation and release of cytokine and growth factors, that activate mechanisms of reparative processes. However, in case of wounds colonized with pathogenic microflora natural regenerative mechanisms become substantially impaired, that could lead to chronic inflammatory states with non-healing skin lesions. Herein, we present the initial results of our studies aimed at the design of bifunctional peptide-based compounds. The chemical approach, that was utilized in this work, was based on the conjugation of antimicrobial peptides with the peptides, that have potential pro-proliferative and/or cytoprotective activity towards human keratinocytes and fibroblasts, in order to obtain antimicrobials with reduced cytotoxicity or compounds that maintain both activities, i.e. inhibit bacterial or fungi growth and activate cell proliferation/migration in in vitro tests. As a result, we obtained a group of peptide conjugates that effectively inhibited the growth of selected bacterial and fungi strains and were able to stimulate proliferation and migration of keratinocytes and fibroblasts under their effective microbicidal concentrations.

Ecthyma mimicking cutaneous leishmaniasis

Chronic non-healing ulcerated skin lesion can be a diagnostic dilemma for the dermatologist in an area endemic with cutaneous leishmaniasis. The differential diagnosis may include a large list of cutaneous diseases ranging from infection to advanced skin cancers. Ecthyma is cutaneous infection caused by group A beta-hemolytic streptococci or Staphylococcus aureus bacteria with dermal and subcutaneous invasion. Ecthyma is a differential diagnosis for cutaneous Leishmaniasis presenting as an ulcerated lesion in endemic areas. Being in endemic area for cutaneous leishmaniasis, general physicians and some dermatologist may miss other important and common differential diagnosis, resulting in delay of proper management and increase risk of complications. Our aim in this work is to draw the attentions toward better management while dealing with ulcerated cutaneous lesions. Method: Case reporting. Result: This is a case of a 60 year-old Sudanese male patient who presented with a chronic nonhealing ulcerated lesions at his right forearm for 4 months. The patient was misdiagnosed as a case of cutaneous leishmaniasis and he was treated with anti-leishmanial therapy with no improvement. He was finally diagnosed to have staphylococcal ecthyma that successfully responded to oral antibiotic. Conclusion: Dealing with chronic ulcerated skin lesion requires a carful and detailed history taking and a good knowledge of the common and endemic diseases in the patient’s area supported by proper laboratory studies

Cell therapy with human MSCs isolated from the umbilical cord Wharton jelly associated to a PVA membrane in the treatment of chronic skin wounds.

The healing process of the skin is a dynamic procedure mediated through a complex feedback of growth factors secreted by a variety of cells types. Despite the most recent advances in wound healing management and surgical procedures, these techniques still fail up to 50%, so cellular therapies involving mesenchymal stem cells (MSCs) are nowadays a promising treatment of skin ulcers which are a cause of high morbidity. The MSCs modulate the inflammatory local response and induce cell replacing, by a paracrine mode of action, being an important cell therapy for the impaired wound healing. The local application of human MSCs (hMSCs) isolated from the umbilical cord Wharton's jelly together with a poly(vinyl alcohol) hydrogel (PVA) membrane, was tested to promote wound healing in two dogs that were referred for clinical examination at UPVET Hospital, showing non-healing large skin lesions by the standard treatments. The wounds were infiltrated with 1000 cells/µl hMSCs in a total volume of 100 µl per cm2 of lesion area. A PVA membrane was applied to completely cover the wound to prevent its dehydration. Both animals after the treatment demonstrated a significant progress in skin regeneration with decreased extent of ulcerated areas confirmed by histological analysis. The use of Wharton's jelly MSCs associated with a PVA membrane showed promising clinical results for future application in the treatment of chronic wounds in companion animals and humans.

Safety of Injecting Insulin Through Clothes: A Case of Mycobacterium immunogenum Cutaneous Infection and Review of the Literature

L.S., a 47-year-old white woman with type 1 diabetes, a bleeding diathesis, and iron deficiency anemia, was referred to an infectious diseases physician for assessment of a painful, nonhealing skin lesion. Before the referral, her primary care physician had treated her with several courses of oral antibiotics, including cephalexin, clindamycin, and amoxicillin, without improvement. She denied a history of preceding trauma, recent foreign travel, or exposure to aquatic animals or hot tubs. When questioned about whether the lesion was at the site of insulin injection, she stated this was possible because she had injected insulin at various locations through her clothes since adolescence, as instructed. On physical examination, the patient appeared well. Her skin examination was significant for a 5-cm erythematous, tender nodule on the anteromedial aspect of her right thigh (Figure 1). No drainage from the lesion or evidence of surrounding cellulitis was found. There was no associated lymphadenopathy, and the remainder of her physical examination was unremarkable. Routine laboratory tests, including leukocyte count with differential, platelets, electrolytes, creatinine, and liver enzymes, were within normal ranges. Her A1C was elevated at 10.8%. Histology of the biopsied lesion demonstrated nonspecific inflammation with negative stains for acid-fast bacilli (AFB) and fungi. Cultures, however, were positive for mycobacteria spp. after an extended incubation period of 63 days (compared to the conventional incubation period of 49 days). 16S rRNA sequencing identified the organism as Mycobacterium immunogenum . The antimicrobial agents the organism was susceptible to were limited to clarithromycin and tigecycline, with intermediate sensitivity to amikacin. The organism was resistant to ciprofloxacin, doxycycline, cefoxitin, imipenem, cotrimoxazole, and linezolid. 1. How did this …

Detection of novelLAMA3mutation in Herlitz junctional epidermolysis bullosa in a Jordanian family

The Herlitz junctional epidermolysis bullosa (H-JEB) subtype usually presents as a severe lethal inherited variant of epidermolysis bullosa (EB) caused by a homozygous mutation in the genes LAMA3, LMAB3, or LAMAC3. Each gene encodes one of the three chains of heterotrimer laminin-332 proteins (including the alpha-3 chain, beta-3 chain and gamma-2-chain) responsible for the adherence of the epidermis to the underlying dermis. The aim of this report is to add to the existing knowledge about EB by describing a novel mutation in a gene responsible for genodermatosis. A case of a Jordanian male neonate, born to healthy, first cousin consanguineous parents, who developed nonhealing blistering skin and mucous membrane lesions, crusted erosions with significant granulation tissue and dystrophic nails immediately after birth is described. The patient was diagnosed as having a novel LAMA3 mutation causing (H-JEB) by immunofluorescence mapping and molecular analysis. Both parents and this baby's sibling were shown to be heterozygous carriers of the same mutation. Pre-implantation diagnosis using molecular analysis for subsequent pregnancies in this family is crucial for managing any new pregnancy.

The treatment of skin ulcers in systemic sclerosis: use of granulocyte-colony stimulating factor (G-CSF) in 26 patients

To verify the effectiveness of G-CSF in the treatment of non-healing skin lesions in SSc patients. 26 SSc patients (23 F and 3 M, age 54 +/-13,6 yrs) with skin ulcers were enrolled in a pilot study. Prior to the treatment with G-CSF, all ulcers failed to heal with conventional therapies carried out for a period of 1-5 years. All patients were treated with 5 microg/kg G-CSF subcutaneously for 5 days. Healing time, quality of wounds, VAS and HAQ-DI were used to evaluate the efficacy of the treatment. An improvement of skin ulcers was observed in 24/26 patients; in particular, 22/26 wounds completely healed, 2/26 showed a partial healing, in only 2 patients skin ulcers did not change during the 6-month follow-up. The quality of life improves as showed by VAS (from 88+/-13 to 55+/-28; p<.0001) and HAQ (from 2.12 +/-0.45 to 1.28+/-0.30; p<.0001). The eradication of pathogens from the infected ulcers was also observed in 12/12 patients; while no adverse side effects related to G-CSF were recorded. Our study suggests that G-CSF may be usefully employed in scleroderma skin ulcers refractory to conventional treatments.

Insights on the Role of Diabetes and Geographic Variation in Patients with Criticial Limb Ischaemia

Background Patients with critical limb ischaemia (CLI) unsuitable for revascularisation have a high rate of amputation and mortality (30% and 25% at 1 year, respectively). Localised gene therapy using plasmid DNA encoding acidic fibroblast growth factor (NV1FGF, riferminogene pecaplasmid) has showed an increased amputation-free survival in a phase II trial. This article provides the rationale, design and baseline characteristics of CLI patients enrolled in the pivotal phase III trial (EFC6145/TAMARIS). Methods An international, double-blind, placebo-controlled, randomised study composed of 525 CLI patients recruited from 170 sites worldwide who were unsuitable for revascularisation and had non-healing skin lesions was carried out to evaluate the potential benefit of repeated intramuscular administration of NV1FGF. Randomisation was stratified by country and by diabetic status. Results The mean age of the study cohort was 70 ± 10 years, and included 70% males and 53% diabetic patients. Fifty-four percent of the patients had previous lower-extremity revascularisation and 22% had previous minor amputation of the index leg. In 94% of the patients, the index leg had distal occlusive disease affecting arteries below the knee. Statins were prescribed for 54% of the patients, and anti-platelet drugs for 80%. Variation in region of origin resulted in only minor demographic imbalance. Similarly, while diabetic status was associated with a frequent history of coronary artery disease, it had little impact on limb haemodynamics and vascular lesions. Conclusions Clinical characteristics and vascular anatomy of CLI patients with ischaemic skin lesions who were unsuitable for revascularisation therapy show little variations by region of origin and diabetic status. The findings from this large CLI cohort will contribute to our understanding of this disease process. This study is registered with ClinicalTrials.gov, number NCT00566657.