Perianal Area Research Articles

Hypervirulent Streptococcus agalactiae septicemia in twin ex-premature infants transmitted by breast milk: report of source detection and isolate characterization using commonly available molecular diagnostic methods

BackgroundGroup B Streptococcus (GBS) infections caused by Streptococcus agalactiae is a leading cause of meningitis and sepsis in neonates, with early-onset GBS symptoms emerging during the first week of life and late-onset occurring thereafter. Perinatal transmission of GBS to the neonate through the birth canal is the main factor associated with early-onset neonate infections, while less is understood about the source of late-onset infections.MethodsIn this report we describe a case of twin ex-premature infants who presented one month after birth with GBS septicemia. The mother had been appropriately screened at gestational age 35–37 weeks and laboratory methods failed to detect GBS colonization by culture or clinical molecular methods. In attempts to identify and isolate the source of GBS infection, additional surveillance swabs were collected from the mother at the time of neonate admission. Culture and a commercially available, FDA-cleared molecular PCR assay were performed.ResultsNo GBS was detected from swabs collected from the perianal, thigh/groin or axillary areas. However, expressed breast milk and swabs from the breastmilk pump were positive by both methods. Since simultaneous culture and molecular methods which used breastmilk as a source were performed, investigators ascertained the limit of detection for GBS in breastmilk. The limit of detection was determined to be tenfold lower than that of LIM-broth enriched cultures—the FDA-approved source. Subsequent whole genome sequencing (WGS) analysis of isolates recovered from breastmilk and blood cultures from the infants demonstrated all strains were related and characterized as ST-452. Both infants responded very well to treatment and continued to have no related events or concerns at the two-year follow up appointment.ConclusionsStrain type 452 (capsular type IV) has recently emerged as a hypervirulent strain and has previously been documented as causing GBS infections in elderly populations. Antibiotic therapy resolved both mother and infant infections. Subsequent testing for the presence of GBS in breastmilk samples also showed an absence of bacteria. This is the first report of infant twins late-onset GBS infections caused by the hypervirulent S. agalactiae ST-452 with breastmilk as the source.

Prevalence of methicillin-sensitive, methicillin-resistant Staphylococcus aureus, and extended-spectrum beta-lactamase-producing Escherichia coli in newborns: a cross-sectional study

Background The prevalence of antimicrobial-resistant bacteria and methicillin-sensitive Staphylococcus aureus (MSSA) in healthy newborns and the role of maternal transmission are scarcely discussed. Objectives The objective of this study was to evaluate the prevalence of MSSA, MRSA, and ESBL among healthy newborns. Additionally, mother-to-newborn transmission rates were investigated as well as antibiotic susceptibility of MSSA, MRSA, and ESBL isolates. Methods Swabs of 658 newborns and their mothers were collected to investigate the presence of MSSA, MRSA, and ESBL. Swabs were taken from the nose and umbilicus immediately after birth. Additional swabs were taken from the nose, perianal area, and umbilicus 3 days after birth. Samples were screened and further characterized using culture and molecular methods. Results Prevalence of MSSA, MRSA, and ESBL colonization was 10.9, 0.5, and 2.6%, respectively. There was no association between the colonization status of the newborn and infections at any time point. Mother-to-newborn transmission rates (confirmed by PFGE) were 53.6% for MSSA/MRSA and 100% for ESBL. Maternal carriage of MSSA, MRSA, or ESBL was a risk factor for colonization of the newborn. Some isolates were resistant to the antibiotics recommended for therapy, including clindamycin and daptomycin for MSSA/MRSA isolates and ertapenem, fosfomycin, and tigecyclin for ESBL isolates. Conclusion No association between infections and the newborns’ colonization status could be detected. Maternal colonization played an important role in newborn colonization, but not every case of colonization could be explained by mother-to-newborn transmission. General screening of pregnant women and healthy newborns in the absence of other risk factors is not necessary. To prevent the possibility of transmission in the healthcare setting, professionals, pregnant women, parents, hospital visitors, and obstetricians should receive regular training on appropriate hygiene measures. With regard to the emergence of resistance to recommended antibiotics, an antibiogram should be conducted before treating MSSA/MRSA/ESBL infections to ensure the efficacy of the antibiotics.

PERANAN 3D AXIAL HYPERCUBE T2 FAT SAT PADA PEMERIKSAAN MRI PELVIS DENGAN KASUSU FISTULA PERIANAL

Background: Fistula is an abnormal relationship between two berepitel places. Fistula ani is a fistula that connects the anal canal to the skin around the anus (or to other organs such as the vagina). Magnetic Resonance Imaging (MRI) Pelvis is one of the right modalities to describe anatomical abnormalities of the pelvis, with the selection of appropriate protocol sequences so that informative MRI images are obtained.
 Method: This research is a qualitative detiptive study using a sample of 5 patients, with the same complaints, there are lumps such as ulcers in the anus area and there are eyes that secrete fluids such as pus and without a previous medical history. Mri Pelvic examination without contrast using MRI 1.5 Tesla Signa Explorer GE brand in Radiology RS EMC Tangerang. Taking a T2 axial sekuen to see the entire pelvis. Focus on perianal fistula area with sagittal sekuen T2, sagittal T2 fat sat, axial T2, axial T2 fat sat, coronol T2, coronal T2 fat sat and 3D axial hypercube T2 fat sat.
 Results: Sagittal T2 fat sat, axial T2 fat sat, and coronal T2 fat sat appear anatomically from perianal fistula and other abnormalities around them. In 3D axial hypercube T2 fat sat obtained anatomical picture of perianal fistula with thinner slice thickness.
 Conclusion: Mri Pelvis without contrast is a very accurate diagnostic imajing in showing perianal fistula abnormalities with a clear anatomical picture, is a non-inspative examination. Uses axial T2 sekuen for the entire pelvis. Sagittal T2, sagittal T2 fat sat, axial T2, axial T2 fat sat, coronal T2, coronal T2 fat sat, 3D axial hypercube T2 fat sat focus on perianal fistula area.

Perianal Traumatic Myiasis in a Goat Caused by Wohlfahrtia magnifica (Schiner 1862) (Diptera: Sarcophagidae) in Konya Province of Turkey

Introduction: The infestation of live humans and animals with dipterous larvae is called Myiasis. These larvae feed on the living or dead tissues, body fluids, and ingested foods of hosts at least for a certain period in myiasis cases. Case Presentation: During clinical examination, several larvae were detected in the perianal area of a goat at Selcuk University, Faculty of Veterinary Medicine, Internal Medicine Clinics. All visible larvae were cleaned by the clinician with the help of forceps. Ivermectin administered against larvae possibly penetrated deep into the wound. A topical antibiotic was also applied, and the wound was washed with an antiseptic solution. Several larvae were preserved in tubes including ethanol (70%) and transferred to parasitology laboratory. Firstly, the larvae were incised with a scalpel and cleared in potassium hydroxide (10%). Then, they were rinsed in distilled water, put into 70% ethanol for dehydration, and stored in 99% ethanol until dissection. The larvae were morphologically examined under a stereo microscope and dissected. The larvae were identified as third instar larvae of Wohlfahrtia magnifica according to the morphological characteristics of cephalo-pharyngeal skeleton, anterior spiracles, and peritremes. Conclusion: It should be kept in mind that in myiasis cases, early diagnosis is a very important factor in preventing deep tissue loss.

Aetiology and pathogenesis of hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is a chronic inflammatory disorder. Patients develop inflamed nodules and abscesses and, at later stages of disease, epithelialized tunnels and scars in skinfolds of axillary, inguinal, gluteal and perianal areas. Quality of life is affected due to severe pain, purulent secretion, restricted mobility and systemic involvement. Genetics and lifestyle factors including smoking and obesity contribute to the development of HS. These factors lead to microbiome alteration, subclinical inflammation around the terminal hair follicles, and infundibular hyperkeratosis, resulting in plugging and rupture of the follicles. Cell-damage-associated molecules and propagating bacteria trigger inflammation and lead to massive immune cell infiltration that clinically manifests as inflamed nodules and abscesses. The immune system plays a key role also in the progression and chronification of skin alterations. Innate proinflammatory cytokines (e.g. interleukin-1β and tumour necrosis factor-α), mediators of activated T helper (Th)1 and Th17 cells (e.g. interleukin-17 and interferon-γ), and effector mechanisms of neutrophilic granulocytes, macrophages and plasma cells are involved. Simultaneously, skin lesions contain anti-inflammatory mediators (e.g. interleukin-10) and show limited activity of Th22 and regulatory T cells. The inflammatory vicious circle finally results in pain, purulence, tissue destruction and scarring. Chronic inflammation in patients with HS is also frequently detected in organs other than the skin, as indicated by their comorbidities. All these aspects represent a challenge for the development of therapeutic approaches, which are urgently needed for this debilitating disease. This scholarly review focuses on the causes and pathogenetic mechanisms of HS and the potential therapeutic value of this knowledge.

Simplifying Surveillance Sampling: Can Environmental Surveillance Replace Perianal Screening?

Background: Although active surveillance for multidrug-resistant organism (MDRO) colonization permits timely intervention, obtaining cultures can be time-consuming, costly, and uncomfortable for patients. We evaluated clinical differences between patients with and without attainable perianal cultures, and we sought to determine whether environmental surveillance could replace perianal screening. Methods: We collected active surveillance cultures from patient hands, nares, groin, and perianal area upon enrollment, at day 14, and monthly thereafter in 6 Michigan nursing homes. Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and resistant gram-negative bacilli (RGNB) were identified using standard methods. Patient characteristics were collected by trained research professionals. This substudy focused on visits during which all body sites were sampled. To determine the contribution of perianal screening to MDRO detection, site of colonization was categorized into 2 groups: perianal and non-perianal. We evaluated the utility of multisite surveillance (eg, type 1 and type 2 error) using nonperianal sites and environment surveillance. To evaluate characteristics associated with the acquisition of perianal cultures (eg, selection bias), we compared clinical characteristics, overall patient colonization, and room environment contamination of patients in whom all body sites were sampled during a study visit (533 patients; 1,026 visits) to patients with all body sites except the perianal culture sampled during a study visit (108 patients; 168 visits). Results: Of 651 patients, 533 met the inclusion criteria; average age was 74.5 years, 42.6% were male, and 60.8% were white. Of 1,026 eligible visits, 620 visits detected MDRO colonized patients; 155 MRSA, 363 VRE, and 386 RGNB (Table 1). If perianal cultures were not collected, nonperianal surveillance misses 7.7%, 41.3%, and 45.1% of MRSA, VRE, and RGNB colonized visits, respectively. The addition of environmental surveillance to non-perianal screening detected 95.5%, 82.9%, and 67.9% of MRSA, VRE, and RGNB colonized visits, respectively. The specificity of environmental screening was 85.3%, 72.7%, and 73.4% for MRSA, VRE, and RGNB, respectively. Patients without attainable perianal cultures had significantly more comorbidities, worse functional status, shorter length of stay, and higher baseline presence of wounds than patients with attainable perianal cultures; introducing potential selection bias to surveillance efforts (Table 2). No significant differences in overall patient colonization and room contamination were noted between patients with and without attainable perianal cultures. Conclusion: Perianal screening is important for the detection of VRE and RGNB colonization. Infection prevention must be cognizant of the tradeoff between reducing type 2 error and the selection bias that occurs with required attainment of perianal cultures. In the absence of perianal cultures, environmental surveillance improves MDRO detection while introducing type 1 error.Funding: NoneDisclosures: None

S2139 A Pain in the Butt! A Rare Case of Perianal Dieulafoy's Lesion

INTRODUCTION: Dieulafoy's lesion was first reported by Gallard in 1884; however, more appropriately described 14 years later by a French surgeon, Georges Dieulafoy. Dielafoy’s lesions are defined as high-caliber arteries that erode the overlying GI mucosa. The caliber for these arteries is approximately 10x larger than the normal caliber of submucosal vessels. Currently, in literature 70% of lesions occur within the stomach, other common locations include duodenum, distal stomach, esophagus, and in the small intestine. Dieulafoy's lesion within the rectum has been very rarely described in the literature. CASE DESCRIPTION/METHODS: We present the case of an 88-year-old male with benign prostatic hyperplasia and hemorrhoids arriving at the emergency department with a chief complaint of rectal bleeding. The patient stated experienced heavy blood per rectum and tenesmus the morning of coming to the emergency department. Within the emergency department, the patient continuously had blood clots around his anus seen as well as flowing from his rectum. His last colonoscopy was more than 15 years prior. On physical examination: Vitals were within normal limits. The patient's physical examination was benign as well. In terms of his labs, they were mainly remarkable for hemoglobin of 7.2. The patient underwent a CT abdomen pelvis with contrast which showed no cause of reported rectal bleeding identified. He then underwent a bleeding scan which showed no scintigraphic evidence of active GI bleeding. Gastroenterology was consulted and he recommended the patient undergo a colonoscopy. Colonoscopy revealed an dieulafoy lesion with a perianal area with fresh bleeding. During the colonoscopy dieulafoy's lesion was treated successfully with epinephrine and cauterization. The patient did not experience any bleeding following the intervention and was discharged home with outpatient follow-up. DISCUSSION: Dieulafoy's lesion is a rare cause of gastrointestinal bleeding, occurring up to 6% of cases of non-varicose bleeding in the upper GI tract and in 1–2% of all gastrointestinal hemorrhages. However, the prevalence of Dieulafoy's lesion within the anal canal has not yet been described in literature due to its rarity. We have concluded in our case that Dieulafoy's lesion should be an important consideration when tackling patients with lower gastrointestinal bleeding.Figure 1Figure 2

Contamination of Healthcare Worker Personal Protective Equipment with MRSA Outside the Intensive Care Unit Setting

Background: Estimates of contamination of healthcare personnel (HCP) gloves and gowns with methicillin-resistant Staphylococcus aureus (MRSA) following interactions with colonized or infected patients range from 17% to 20%. Most studies were conducted in the intensive care unit (ICU) setting where patients had a recent positive clinical culture. The aim of this study was to determine the rate of MRSA transmission to HCP gloves and gown in non-ICU acute-care hospital units and to identify associated risk factors. Methods: Patients on contact precautions with history of MRSA colonization or infection admitted to non-ICU settings were randomly selected from electronic health records. We observed patient care activities and cultured the gloves and gowns of 10 HCP interactions per patient prior to doffing. Cultures from patients’ anterior nares, chest, antecubital fossa and perianal area were collected to quantify bacterial bioburden. Bacterial counts were log transformed. Results: We observed 55 patients (Fig. 1), and 517 HCP–patient interactions. Of the HCP–patient interactions, 16 (3.1%) led to MRSA contamination of HCP gloves, 18 (3.5%) led to contamination of HCP gown, and 28 (5.4%) led to contamination of either gloves or gown. In addition, 5 (12.8%) patients had a positive clinical or surveillance culture for MRSA in the prior 7 days. Nurses, physicians and technicians were grouped in “direct patient care”, and rest of the HCPs were included in “no direct care group.” Of 404 interactions, 26 (6.4%) of providers in the “direct patient care” group showed transmission of MRSA to gloves or gown in comparison to 2 of 113 (1.8%) interactions involving providers in the “no direct patient care” group (P = .05) (Fig. 2). The median MRSA bioburden was 0 log 10CFU/mL in the nares (range, 0–3.6), perianal region (range, 0–3.5), the arm skin (range, 0-0.3), and the chest skin (range, 0–6.2). Detectable bioburden on patients was negatively correlated with the time since placed on contact precautions (rs= −0.06; P < .001). Of 97 observations with detectable bacterial bioburden at any site, 9 (9.3%) resulted in transmission of MRSA to HCP in comparison to 11 (3.6%) of 310 observations with no detectable bioburden at all sites (P = .03). Conclusions: Transmission of MRSA to gloves or gowns of HCP caring for patients on contact precautions for MRSA in non-ICU settings was lower than in the ICU setting. More evidence is needed to help guide the optimal use of contact precautions for the right patient, in the right setting, for the right type of encounter.Funding: NoneDisclosures: None

Epidemiologic and Microbiologic Characteristics of 28 Hospitalized Patients Cocolonized With Multiple Carbapenem-Resistant Enterobacteriaceae (CRE) in the United States

Background: As carbapenem-resistant Enterobacteriaceae (CRE) prevalence increases in the United States, the risk of cocolonization with multiple CRE may also be increasing, with unknown clinical and epidemiological significance. In this study, we aimed to describe the epidemiologic and microbiologic characteristics of inpatients cocolonized with multiple CRE. Methods: We conducted a secondary analysis of a large, multicenter prospective cohort study evaluating risk factors for CRE transmission to healthcare personnel gown and gloves. Patients were identified between January 2016 and June 2019 from 4 states. Patients enrolled in the study had a clinical or surveillance culture positive for CRE within 7 days of enrollment. We collected and cultured samples from the following sites from each CRE-colonized patient: stool, perianal area, and skin. A modified carbapenem inactivation method (mCIM) was used to detect the presence or absence of carbapenemase(s). EDTA-modified CIM (eCIM) was used to differentiate between serine and metal-dependent carbapenemases. Results: Of the 313 CRE-colonized patients enrolled in the study, 28 (8.9%) were cocolonized with at least 2 different CRE. Additionally, 3 patients were cocolonized with >2 different CRE (1.0%). Of the 28 patients, 19 (67.6%) were enrolled with positive clinical cultures. Table 1 summarizes the demographic and clinical characteristics of these patients. The most frequently used antibiotic prior to positive culture was vancomycin (n = 33, 18.3%). Among the 62 isolates from 59 samples from 28 patients cocolonized patients, the most common CRE species were Klebsiella pneumoniae (n = 18, 29.0%), Escherichia coli (n = 10, 16.1%), and Enterobacter cloacae (n = 9, 14.5%). Of the 62 isolates, 38 (61.3%) were mCIM positive and 8 (12.9%) were eCIM positive. Of the 38 mCIM-positive isolates, 33 (86.8%) were KPC positive, 4 (10.5%) were NDM positive, and 1 (2.6%) was negative for both KPC and NDM. Also, 2 E. coli, 1 K. pneumoniae, and 1 E. cloacae were NDM-producing CRE. Conclusion: Cocolonization with multiple CRE occurs frequently in the acute-care setting. Characterizing patients with CRE cocolonization may be important to informing infection control practices and interventions to limit the spread of these organisms, but further study is needed.Funding: NoneDisclosures: None

Perianal lesions as an unusual first manifestation of Crohn's disease in pediatric patients - case series.

Primary symptoms of Crohn’s disease usually include, among others, abdominal pain and cramping, recurrent diarrhea, fever and weight loss. The aim of this study was to show the effectiveness of ultrasound in the diagnosis and assessment of the extent of perianal complications in Crohn’s disease. Five patients (four boys and one girl) aged from 13 to 16 years, with prolonged pain in the perianal area, which worsened when sitting, were admitted to the Department of Pediatric Gastroenterology between 2017 and 2019. Each patient underwent intestinal ultrasound with a high frequency 7–12 MHz linear probe and transperineal ultrasound to assess the anal canal and the surrounding soft tissues. In each case, the echogenicity of the bowel wall was assessed for mural stratification and possible thickening. Anorectal fistulas were detected in all the five patients. Three patients (12 y.o. male, 12 y.o. female and 16 y.o. male) presented with perianal abscesses drained by fistulas. In the first patient the fistula was limited to the perianal soft tissue (22 × 23 mm); in the second patient it was localized within the ischioanal region (40 × 50 mm); and in the third patient (5–6 mm abscess) the fistula was with a hypoechoic fistulous tract reaching the sphincter. All of the patients were eventually diagnosed with Crohn’s disease as a result of further clinical workup. Ultrasound examination is a non-invasive, well-tolerated modality for the evaluation of Crohn’s disease activity and its possible complications, e.g. fistulas and abscesses. Ultrasound is especially useful in patients who require repeated follow-up investigations.

Clinical Characteristics, Treatment, and Prognostic Factors of Patients With Primary Extramammary Paget's Disease (EMPD): A Retrospective Analysis of 44 Patients From a Single Center and an Analysis of Data From the Surveillance, Epidemiology, and End Results (SEER) Database.

Objective: Primary extramammary Paget's disease (EMPD) is a rare cutaneous malignancy. The aim of this article is to analyze clinical characteristics, evidence of the prognosis, and share treatment experience of primary EMPD.Methods: We extracted 771 patients' data from the Surveillance, Epidemiology, and End Results (SEER) program between 1973 and 2013 to investigate the characteristics and prognosis of patients with EMPD. In addition, 44 patients with primary EMPD in our hospital were retrospectively reviewed for 10 years.Results: Compared with patients younger than 65 years, patients diagnosed at 65–74 years [hazard ratio (HR), 2.453] and 75 years or older (HR, 5.750) had shorter survival. Patients with a primary site in the truncal skin (HR, 0.367) or scrotum (HR, 0.246) had better survival compared to those with a primary site in the perianal area. Compared with localized EMPD, EMPD with distant (HR, 18.821) and regional (HR, 2.180) metastases was associated with a worse prognosis. Patients who received radiotherapy had decreased survival, with an HR of 2.039. Patients with a higher N stage, M stage, and American Joint Committee on Cancer (AJCC) stage had a decreased prognosis (p < 0.001).Conclusions: Older age at diagnosis, primary site in the perianal area, distant metastasis, radiotherapy, and higher N stage, M stage, and AJCC stage may result in decreased survival.

A CASE STUDY ON FOURNIER’S GANGRENE IN AN EPILEPTIC PATIENT WITH THE EMERGENCE OF ANTIBIOTIC RESISTANCE IN BACTERIA

Fournier's gangrene is rare necrotizing soft tissue infection affecting the perianal, perineal, and genital areas. The mean age of the reported cases was found to be at 55 y, predominantly in men. It occurs due to insufficient blood supply to the affected areas, along with the presence of an infection. Delay in the treatment is associated with a higher mortality rate, up to 90%, as the condition might progress to septic shock and other complications. Treatment requires urgent surgical debridement of all the necrotic tissue along with high doses of broad-spectrum antibiotics. Empirical broad-spectrum antibiotic therapy is to be initiated as soon as possible until the results of the culture cause modifications in the therapy.

Malakoplakia of the gastrointestinal tract: clinicopathologic analysis of 23 cases

BackgroundMalakoplakia is an uncommon, tumor-like inflammatory disease characterized by impaired histiocytes that are unable to completely digest phagocytized bacteria. The genitourinary tract is the most common site of involvement, however, cases have also been described in the gastrointestinal tract, suggesting that it is the second most common site of involvement. This study investigates the clinical and histologic features of malakoplakia in the gastrointestinal tract.Case presentationFor 23 gastrointestinal specimens (biopsies and resections) from patients with a pathologic diagnosis of malakoplakia, we recorded the gender, age, location, primary diagnosis, endoscopic or surgical indication, endoscopic/gross impression and immune status (immunocompromised vs. immunocompetent).ConclusionMalakoplakia occurred throughout the length of the gastrointestinal tract with most of the cases located in the sigmoid colon and rectum (n = 10); other sites included the transverse and descending colon (n = 4), stomach/gastroesophageal junction (n = 4), appendix (n = 2), cecum (n = 1), small bowel (n = 1), and the peri-anal area (n = 1). Endoscopically, these lesions most commonly appeared as polyps (n = 10) or masses (n = 5), other clinical endoscopic impressions varied from a thickened area/fibrosis to mucosal erythema. Most patients were immunocompromised due to a disease state (e.g. organ transplantation, cancer diagnosis, autoimmune condition) and/or medication effect. Eight patients with malakoplakia were on immunosuppressive medications (8/23, 35%). Common immunosuppressed disease states included cancer (n = 9), autoimmune disease (n = 5), status post organ transplantation (n = 4), diabetes (n = 5), infection/sepsis (n = 3), and HIV/AIDS (n = 1). Some patients had multiple co-morbidities (i.e. diabetes and organ transplant). Twenty-one patients with malakoplakia were in an immunosuppressive state (21/23, 91%).

Urethral Orifice Genital Herpes Caused by HSV-1 in a Female Patient: A Case Report

Abstract Introduction: Genital herpes is one of the most common sexually transmitted infections worldwide. Most genital herpes occur on the genitalia, perineum, buttocks, upper thighs, or perianal areas. However, there were reports of rare cases of genital herpes on urethral orifice. Herein, we report a case of a patient who was diagnosed with urethral orifice genital herpes, a place likely to be ignored. Case presentation: A 53-year-old woman presented with vagina pruritus at first, with subsequent burning sensation around urethra. Mycostatin and mycospor were administered for the treatment of the pruritus. Then levofloxacin was prescribed. Finally, the patient was given treatment with acyclovir. Different from other cases, the investigation showed herpes simplex virus type 1 DNA positive and herpes simplex virus type 2 DNA negative by PCR. The patient was therefore diagnosed with genital herpes. Discussion: Most genital herpes happen on the genitalia, perineum, buttocks, upper thighs, or perianal areas. Few cases have been reported that genital herpes occurred on urethral orifice till now. Conclusion: If there is no typical symptoms that patient present with herpes simplex virus type 1 or 2 positive, urethral orifice genital herpes should be considered.

Humans as Accidental and Natural Hosts for Worms.

Worms and creepy crawly creatures are often associated with an “ick factor.” In this time of novel coronavirus 2019 (COVID-19), increased sanitation, handwashing, and social distancing can prepare us for other natural causes of infestations, secondary infections, and sometimes serious sequelae. North Americans enjoy beaches, lakes, and outdoor activities in the summer. As we have recently learned, being aware and prepared can be life saving. After social distancing and many weeks of sheltering at home from COVID-19, being outdoors again will necessarily need to be balanced with caution around other potential (although unusual) infestations and infections. This month’s CE/CME article, Exploring Tropical Infections: A Focus on Cutaneous Larva Migrans (CLM), documents two cases of travelers (to Chile and Jamaica, respectively) who were infected with CLM after walking barefoot on warm, moist surfaces contaminated by dog or cat feces. The egg hatching (first stage) and survival of the developing rhabdiform larvae (second stage) require an additional intermediate host (molluscs) to form filiform larvae (third stage) that can accidently infect human skin.1,2 Feet or lower legs can become infected with the parasite, which leaves the characteristic, migrating, serpiginous trails for several weeks before the larvae die or are destroyed with physical (liquid nitrogen) or chemical (topical or systemic) agents. Infection with CLM may be complicated by secondary bacterial infections, eczematization, local or general allergic reactions, or (in more severe cases) Loeffler syndrome (eosinophilia and transient pulmonary infiltrates). Systemic treatment (as in this month’s CE/CME cases) is not always necessary but ivermectin or albendazole are most effective.3 Although CLM is mostly diagnosed in travelers returning home to North America, we have our own endemic parasitic diseases. These diagnoses are often delayed or initially missed, resulting in severe pruritus, secondary infections, or other complications. For example, pinworms (thin, white roundworms that cause enterobiasis) lay eggs in the perianal areas of humans–most commonly in young children. Look for them 3 hours after the victim falls asleep, take tape samples on three consecutive mornings for eggs, or examine the skin under the nails for eggs with a dermatoscope. Over-the-counter or prescription medication can successfully treat this infestation.4 That said, hemorrhoids, contact dermatitis, and other causes of perianal itch also exist. Another infection that can affect individuals of any age, often after swimming in freshwater lakes or saltwater oceans, is cercarial dermatitis. Called swimmer’s itch, parasites released by infected snails burrow into the skin, causing an allergic reaction. Austrobilharzia variglandis require a primary host (often birds–especially geese) or other mammal species to complete their life cycle. Related lesions under bathing garments can be numerous, especially around the buttocks, and are self-limiting but may require topical steroids and oral antihistamines.5 Keep the cream in the refrigerator for a greater cooling effect! One of the authors (Dr Sibbald) encountered a life-changing case as a final year medical student. A previously healthy young patient went on a camping and canoeing trip with a friend. After his return, he was admitted to a tertiary hospital ICU and placed on a ventilator for respiratory failure. His skin developed hemorrhagic lesions and he had diffuse pulmonary infiltrates. A lung biopsy revealed mesocercariae of the trematode Alaria americana. It was later determined that this parasite was contracted from inadequately cooked frogs’ legs the patient ate less than 2 weeks before he succumbed to his illness. Many thousands of organisms were found within most of his internal organs.6 Although we may not like to think about it, parasites and their associated clinical syndromes are ubiquitous. Just like the precautions for COVID-19, we need to consider good hygiene and public health precautions around time spent in natural settings, swimming, or in contact with wildlife and domestic animals. This July, as always, please be smart, be safe, and enjoy the environment by giving it the respect it deserves! R. Gary Sibbald, MD, DSc (Hons), MEd, BSc, FRCPC (Med Derm), FAAD, MAPWCA, JM Elizabeth A. Ayello, PhD, MS, BSN, RN, CWON, ETN, MAPWCA, FAAN

The 'transverse guard' wound dressing technique to reduce faecal contamination after spinal surgery in neonates and infants.

Wound care following lower spinal surgery in infants, especially open lumbosacral myelomeningocele (MMC) repair is challenging for a number of reasons: the babies' small size, uneven contour of the natal cleft, proximity of the wound to the perianal area, continuous soiling by loose/poorly-formed stool, and fragile skin. Faecal contamination of the wound can lead to infection, ascending meningitis and further morbidity. A single adhesive dressing does not reliably obliterate the space in the natal cleft and, therefore, does not prevent faecal material tracking rostrally underneath the dressing. This increases the risk of contamination and necessitates frequent wound dressing changes. The authors describe the use of the 'transverse guard', a simple technique routinely used in their unit that help overcome these problems. They also report on the wound infection rates of neonates undergoing open MMC repair who had the new dressings versus those who had conventional dressings.

Lesions of anogenital mammary-like glands: Four cases including novel pathologic and immunohistochemical observations

Anogenital mammary-like glands, formerly described as ectopic breast tissue, are currently considered to be normal histologic components of the anogenital region. Anogenital mammary-like glands can give rise to many lesions identical to counterparts in the native female breast. We describe four cases of such lesions, including fibroadenoma, gynecomastia-like hyperplasia, and ectopic mammary-type tissue with a spectrum of usual ductal hyperplasia, apocrine metaplasia, adenosis, and pseudolactational change. All four cases occurred in young women (ages 29–38) who presented with vulvar or perianal masses. Similar to previously reported cases, these lesions shared histologic and immunohistochemical characteristics identical to native female breast lesions. Novel findings in our cases included (1) the first case of gynecomastia-like change to be reported in the perianal area of a female, (2) Immunohistochemical staining identifying a 3-layered epithelium characterized by a population of CK14 and CK5/6 positive and hormone receptor negative superficial luminal cells, and (3) diffuse, strong positivity for GATA3 in all cases. Our study adds to the literature on these rare lesions and highlights findings which may be useful in understanding the pathogenesis and improving the diagnosis of anogenital mammary-like gland lesions.

Therapeutic Options for Hidradenitis Suppurativa: An Update

Hidradenitis suppurativa (HS) is chronic deteriorating skin condition characterized by severe, deep inflammatory lesions, often referred to as acne inversa. Intertriginous regions, such as the axillae, groins (genital, anal, and perianal areas), infra- and intermammary skin, buttocks, and upper thighs, are usually affected although there can also be other areas, such as the neck and the stomach. Patients with severe conditions are affected by several painful nodules and draining sinuses, which exude fluid that often smells, and the fear that those new lesions can erupt at any time, requiring incision and drainage, corticosteroid, or surgical injection. Topical clindamycin lotion or resorcinol cream can be effective long-term treatment in mild disease, while tetracycline is mostly systemic first-line choice. Although antibiotics can help to reduce inflamed lesions, but recurrence is significant after discontinuation. If patients do not respond well to these common medical procedures, the next step is to use biologics such as adalimumab or infliximab. Several anti-inflammatory medications such as fumarate, dapsone, and cyclosporine have been also recommended for the treatment of HS. Surgical procedures, particularly when sinuses or scares are present, are often important for healing. The HS clinical interpretation and patients’ expectations should be used as a basis for each patient therapy.

Characteristics of microflora involved in the development of purulent paraproctitis and its sensitivity to ozone

Annotation. Despite significant advances in surgery to overcome purulent complications, the development of acute paraproctitis remains an extremely pressing problem, accounting for up to 4% of surgical pathology. This article is devoted to the study of the microbial spectrum of pathogens that contribute to the development of acute paraproctitis and Fournier gangrene, as the extreme degree of exposure of the subcutaneous adipose tissue of the external genitalia and perianal area in men. To study the microbial spectrum of pathogens of this pathology used the rules of intake, transportation of the studied material according to the Order of the Ministry of Health of Ukraine No. 234 on the organization of prevention of nosocomial infections in obstetric hospitals. The identification of isolated cultures was performed considering morphological, cultural and biochemical characteristics. Biochemical typing was performed using PLIVA diagnostic test systems – Lachema a. s. Brno, Czech Republic (NEFERMtest 24, STAPHYtest 16, ENTEROtest 24). To evaluate the effectiveness of the decontamination effect of ozonized sodium chloride solution, a quantitative suspension test was introduced with the introduction of a suspension of microorganisms isolated from the test material, followed by seeding on dense nutrient media to calculate the number of viable cells to reduce the exposure to the specified ex ante. The purpose of the study was to study the disinfecting effect of ozonated sodium chloride solution to improve the effectiveness of treatment of patients with acute paraproctitis. The results of the study indicate that the use of ozonated sodium chloride solution has significant advantages over the use of 0.02% solution of furacilin and decasan in the treatment of patients with acute paraproctitis and significantly reduces the risk of complications and accelerates the recovery of patients. The results of the research prove that the ozonated solution of sodium chloride in two dilutions (1:1), in contrast to other antiseptics, retains bactericidal action against the whole spectrum of bacteria that are most often involved in the development of acute paraproctitis. Thus, we consider it appropriate to include this solution in the scheme of complex treatment of patients with acute paraproctitis.

Etiology, Clinical Features, and Diagnosis of Vulvar Lichen Sclerosus: A Scoping Review.

Objective. Vulvar lichen sclerosus (VLS) is a chronic inflammatory disorder, which affects women of all ages. With numerous controversies as regards to the nomenclature, diagnosis and its association with neoplastic conditions, we decided to conduct a scoping review on this subject. Data Source. A review protocol was developed, and the Knowledge Resource Services website was used to do a search of articles pertaining to VLS with keywords “Vulvar,” “Vulval,” “diagnosis,” “lichen sclerosus et atrophicus,” “kraurosis,” “vulvar dystrophy,” and “Lichen Sclerosus”. Study Selection. The search was limited to published data from the last ten years, i.e., from July 2009 onwards and in the English language. A total of 338 articles pertaining to VLS were obtained. Older data were accessed if particular information was sought for. Results & Conclusion. The presentation is bimodal, i.e., one in prepubertal girls (average age: 7.6 years) and the other in peri- and postmenopausal women (average age: 52.6 years). However, many cases also present during reproductive years. Studies suggest a multifactorial origin as far as etiology is concerned, including a genetic, autoimmune, hormonal, and local infectious background. It affects the genital labial, perineal, and perianal areas and manifests as a patchy, thin, glistening, ivory-white area. Diagnosis is mainly based on clinical features. Biopsy is seldom required. It has been well established as a precursor lesion of dVIN and vulvar carcinoma.