Recurrent Soft Tissue Infections Research Articles

Characterisation of PVL-Positive Staphylococcus argenteus from the United Arab Emirates.

Staphylococcus argenteus is a recently described staphylococcal species that is related to Staphylococcus aureus but lacks the staphyloxanthin operon. It is able to acquire both resistance markers such as the SCCmec elements and mobile genetic elements carrying virulence-associated genes from S. aureus. This includes those encoding the Panton-Valentine leukocidin (PVL), which is associated mainly with severe and/or recurrent staphylococcal skin and soft tissue infections. Here, we describe the genome sequences of two PVL-positive, mecA-negative S. argenteus sequence type (ST) 2250 isolates from the United Arab Emirates in detail. The isolates were found in a dental clinic in the United Arab Emirates (UAE). Both were sequenced using Oxford Nanopore Technology (ONT). This demonstrated the presence of temperate bacteriophages in the staphylococcal genomes, including a PVL prophage. It was essentially identical to the published sequence of phiSa2wa_st78 (GenBank NC_055048), a PVL phage from an Australian S. aureus clonal complex (CC) 88 isolate. Besides the PVL prophage, one isolate carried another prophage and the second isolate carried two additional prophages, whereby the region between these two prophages was inverted. This "flipped" region comprised about 1,083,000 bp, or more than a third of the strain's genome, and it included the PVL prophage. Prophages were induced by Mitomycin C treatment and subjected to transmission electron microscopy (TEM). This yielded, in accordance to the sequencing results, one or, respectively, two distinct populations of icosahedral phages. It also showed prolate phages which presumptively might be identified as the PVL phage. This observation highlights the significance bacteriophages have as agents of horizontal gene transfer as well as the need for monitoring emerging staphylococcal strains, especially in cosmopolitan settings such as the UAE.

Panton-Valentine leukocidin-induced neutrophil extracellular traps lack antimicrobial activity and are readily induced in patients with recurrent PVL + -Staphylococcus aureus infections.

Staphylococcus aureus strains that produce the toxin Panton-Valentine leukocidin (PVL-SA) frequently cause recurrent skin and soft tissue infections. PVL binds to and kills human neutrophils, resulting in the formation of neutrophil extracellular traps (NETs), but the pathomechanism has not been extensively studied. Furthermore, it is unclear why some individuals colonized with PVL-SA experience recurring infections whereas others are asymptomatic. We thus aimed to (1) investigate how PVL exerts its pathogenicity on neutrophils and (2) identify factors that could help to explain the predisposition of patients with recurring infections. We provide genetic and pharmacological evidence that PVL-induced NET formation is independent of NADPH oxidase and reactive oxygen species production. Moreover, through NET proteome analysis we identified that the protein content of PVL-induced NETs is different from NETs induced by mitogen or the microbial toxin nigericin. The abundance of the proteins cathelicidin (CAMP), elastase (NE), and proteinase 3 (PRTN3) was lower on PVL-induced NETs, and as such they were unable to kill S. aureus. Furthermore, we found that neutrophils from affected patients express higher levels of CD45, one of the PVL receptors, and are more susceptible to be killed at a low PVL concentration than control neutrophils. Neutrophils from patients that experience recurring PVL-positive infections may thus be more sensitive to PVL-induced NET formation, which might impair their ability to combat the infection.

Recurrent Soft Tissue Infections Associated With Burosumab Therapy in X-Linked Hypophosphatemic Rickets

Abstract X-linked hypophosphatemic rickets (XLH) is a genetic disorder characterized by elevated fibroblast growth factor 23 (FGF23), resulting in renal phosphate wasting and inadequate bone mineralization. Burosumab, a monoclonal antibody that inhibits FGF23 activity, has shown promise in improving renal phosphate reabsorption and clinical outcomes in XLH patients. However, the potential side effects of burosumab, particularly its impact on immune function and susceptibility to infections, remain a subject of concern. In this case report, we describe a 57-year-old male individual with XLH who experienced recurrent soft tissue infections while receiving burosumab therapy. The infections included an olecranon abscess, a cervical retropharyngeal phlegmon with a sternocleidomastoid abscess, and suprapubic cellulitis, all of which were treated with antibiotic therapy. Following discontinuation of burosumab therapy, the patient did not experience further soft tissue infections. These observations suggest a potential association between burosumab therapy and an increased risk of soft tissue infections. Mechanistically, disruption of the FGF23-Klotho signaling axis may lead to impaired humoral immunity mediated by B lymphocytes and compromised innate immune response mediated by macrophages. Further investigation is warranted to better understand the immunological effects of burosumab and its implications for infectious complications in XLH patients.

Hepatic safety and efficacy of immunomodulatory drugs used in patients with autoimmune hepatitis

Background and aimsThere is little data on the hepatic efficacy and safety of immunomodulatory drugs used in patients with autoimmune hepatitis (AIH), despite their established use in dermatology, rheumatology and inflammatory bowel diseases (IBD). Our aim was to collect real-life data on the experience of expert centres in treating AIH patients with these drugs, considered unconventional for AIH management. MethodsOnline survey among hepatology centres being part of the European Reference Network on Hepatological Diseases (ERN RARE-LIVER). Results25 AIH patients have been reported. Ten were female, median age at diagnosis was 28 years; median follow-up was 17 months. All had initially received AIH-standard treatment.AIH-unconventional treatment was initiated for concomitant autoimmune diseases in 15 cases: nine for IBD (five vedolizumab and four ustekinumab), and one each for following diseases: autoinflammatory syndrome (tocilizumab), chronic urticaria (omalizumab), rheumatoid arthritis (abatacept), psoriasis (guselkumab), psoriatric arthritis (secukinumab, followed by ustekinumab) and alopecia (ruxolitinib). Three patients were treated with immunomodulatory drugs for side effects of previous treatments, including two patients with IBD treated with vedolizumab and ustekinumab, respectively, and one treated with belimumab. At the end of follow-up, 13 patients were in complete biochemical response, the patient on omalizumab had a relapse, and four patients with concomitant IBD had insufficient response.Seven patients were treated for lack of biochemical remission, of whom six with belimumab, all initially reaching complete biochemical response, but five relapsing during follow-up; and one with secukinumab, having concomitant rheumatoid arthritis and ankylosing spondylitis, reaching complete biochemical response.Only the patient on abatacept received unconventional treatment as monotherapy. Side effects were reported in two patients on belimumab: one recurrent soft tissue infections, one fatigue and arthralgia. ConclusionAmong 25 AIH patients who were treated with immunomodulatory drugs for different reasons, the majority had a fovorable course, relapse was frequent in difficult-to-treat patients who received belimumab, and four with concomitant IBD had insufficient response.

Vulvovaginitis due to methicillin-resistant and methicillin-sensitive Staphylococcus aureus among women in reproductive age-group

Abstract Background: Although Staphylococcus aureus is commensal in 20% of individuals, its pathogenic consequences have not been unidentified. Colonisation of methicillin-resistant S. aureus (MRSA) in the vagina is associated with recurrent vaginal infections, skin and soft tissue infections surrounding the genital and buttock area and infertility. Methods: This study aimed at identifying S. aureus in vaginitis and the antibiotic susceptibility of S. aureus. Results: Of 463 patients’ vaginal swabs, 53 had significant growth, yielding 60 aerobic bacterial isolates. Seven (15%) isolates were S. aureus, 78% were MRSA and 100% were resistant to penicillin. All were sensitive to doxycycline and linezolid. Because the vaginal cavity is a reservoir for S. aureus, genital infections are considered, especially if they are recurring. Conclusions: Among patiens with vaginitis, MRSA is a common aetiological cause and should be tested for.

Calcinosis universalis in systemic sclerosis.

The patient, a 46-year-old woman with a history of systemic sclerosis, interstitial lung disease, and dystrophic calcinosis cutis presented to the emergency department complaining of right thigh pain. Physical examination was notable for a large erythematous, tender, indurated circular area in the medial thigh with many large calcified nodules throughout her thighs. Incision and drainage yielded a small amount of purulent chalky fluid. The patient received antibiotics and was discharged home. Over 5 years, the patient had recurrent soft tissue infections with progressive calcinosis. Her basic metabolic panel was within normal limits (including calcium and phosphorus levels). Computed tomography showed extensive calcification throughout the subcutaneous tissues of the pelvis and bilateral thighs. Some of the calcinosis extended into the intermuscular fascial planes of the adductor and posterior compartment musculature of the bilateral thighs. The patient received nifedipine, mycophenolic acid, rituximab, colchicine, and sodium thiosulfate (topical, intralesional, and intravenous), but her calcinosis continued to progress. Calcinosis is a debilitating condition that occurs in 40% of patients with systemic sclerosis. A long disease duration is associated with progressive calcinosis (1). Thus far, there are no effective treatment options for calcinosis.

1326. Mupirocin Resistance in Staphylococcus aureus in Pediatric Patients for Ten Years

Abstract Background Mupirocin has been recommended for decolonization in methicillin-resistant Staphylococcus aureus (MRSA) carriers for recurrent skin and soft tissue infections and treatment for impetigo. However, the indiscriminate use of mupirocin causes mupirocin resistance, associated with decolonization failure. The aim of the study was to investigate the epidemiology of mupirocin resistance and to identify clinical characteristics among children in a single center. Methods From January 2011 to October 2020, we retrospectively analyzed the epidemiology of antibiotic resistance and clinical characteristics of pediatric patients under 19 years old in whom S. aureus was firstly isolated at any body site. Results Of the 3,414 S. aureus isolates, 46% (1569/3414) were methicillin-resistant, and 20.3% (692/3414) were mupirocin resistant. Among MRSA, Mupirocin-resistant (MupR) was 22.6% (354/1569), and among methicillin-sensitive S. aureus (MSSA), MupR was 18.3% (338/1845) (P< 0.001). The median age of MupR MRSA patients was 0.14 years (interquartile range 0.04-0.79), and the median age of MupR MSSA patients was 5.0 years (interquartile range 2.0-8.1) (P=0.000). Of 692 MupR S. aureus, 94.2% (652/692) were mainly detected in the skin. MupR MRSA was most frequently isolated in the neonatal intensive care unit (40.1%, 142/354), but MupR MSSA was most frequently isolated in the outpatient setting (81.4%, 275/338) (P< 0.001). Of these, 43% (119/275) patients were diagnosed with atopic dermatitis. By age, mupR MRSA was the more commonly isolated in infants younger than one year (77.4%, 274/354), and MupR MSSA was more commonly isolated in children older than three years old (65.4%, 221/338) (P< 0.001). The frequency of MupR MRSA and MSSA showed an increase in trend over time (P< 0.001). Among other topical agents, 6.5% (102/1569) of MRSA was resistant to fusidic acid. Conclusion As mupirocin resistance gradually increases, a test for mupirocin susceptibility should be performed before applying the skin lesions or decolonization for MRSA. In addition, clinicians should carefully prescribe mupirocin to prevent the development of MupR S. aureus. Disclosures Yae-Jean Kim, MD, PhD, Janssen: Grant/Research Support|Korean Society of Pediatric Infectious Diseases: Grant/Research Support|Ministry of Trade, Industry and Energy: Grant/Research Support|MSD: Grant/Research Support.

Mupirocin susceptibility of staphylococci 2022: Is it time for a change in MRSA decolonization protocols?

Nasal decolonization with mupirocin has been a common strategy for the prevention of surgical site infections (SSIs) and recurrent skin and soft tissue infections due to Staphylococcus aureus (SA). We recently noted an increase in SSIs due to SA, including a case of post-operative mupirocin-resistant methicillin-resistant SA (MRSA) infection despite attempted preoperative decolonization with mupirocin. We therefore evaluated the mupirocin susceptibility of SA at our hospital to determine the optimal regimen for decolonization. SA isolates were recovered from clinical and screening samples received in the microbiology laboratory. Mupirocin susceptibility was determined using e-tests and isolates were categorized as susceptible or resistant using a breakpoint MIC value of 4mcg/ml. 223 unique SA isolates from 218 patients were tested. Twenty-four SA isolates (10.8%) were resistant to mupirocin (20 MRSA and 4 methicillin-sensitive SA [MSSA]). MRSA strains were more likely to be resistant to mupirocin than MSSA strains (22.5% vs 3.0%, P < .001). The emergence of drug resistance makes the policy of decolonization with nasal mupirocin a suboptimal strategy for the prevention of MRSA infections. In our study, less than 80% of MRSA strains were mupirocin susceptible. In patients colonized with MRSA at high risk for infection (eg, total joint replacement), other regimens such as intranasal povidone iodine may be preferable to mupirocin for patient decolonization.

Leukocyte Adhesion Deficiency: First Case Report from Bangladesh

Leukocyte Adhesion Deficiency (LAD) is an autosomal recessive immunodeficiency disorder characterized by failure of leukocyte to adhere to endothelium resulting in recurrent overwhelming infection from childhood. Deficiency of CD18 expression due to mutation of beta-2 integrin results in LAD. Persistent neutrophilia without infection and leukemoid reaction during infection is hallmark for LAD. Based on percentage of CD18 expression it can be divided into three types (mild, moderate and severe). Diagnosis requires flow cytometric measurement of CD 18, CD11a, CD11b and CD15a or mutation analysis. We are presenting a 4-year female baby with recurrent skin and soft tissue infection. Diagnosis was suspected by history, physical examination and blood reports and confirmed by flow cytometric measurement of CD18 expression. It reveals LAD type-I severe variety. Allogenic stem cell transplant is the only recommended option for LAD. In other cases, antibiotic and antifungals are the mainstay of conservative management.

Novel mutation in PIK3CD affecting the Ras-binding domain

Introduction: The phosphoinositide 3-kinase (PI3K) pathway plays critical roles in diverse cellular processes, including differentiation, proliferation, motility, survival, and growth. PI3Kδ, comprised of the catalytic subunit p110δ and regulatory subunit p85α, is essential for normal lymphocyte and myeloid development and function. Gain-of-function mutations in PIK3CD (encoding p110δ) cause a combined immunodeficiency known as activated PI3Kδ syndrome (APDS), in which patients frequently present with recurrent respiratory infections, severe recurrent (or persistent) infections with herpes family viruses, and lymphadenopathy. Aim: To describe the clinical presentation, immune evaluation, and genetic work-up of 2 patients (daughter and mother) with recurrent sinopulmonary, soft tissue, and skin infections. Results: Both daughter and mother presented with recurrent sinopulmonary and soft tissue infections. Immune evaluation of the daughter revealed intermittent hypogammaglobulinemia and abnormal specific vaccine responses, while immune parameters of her mother were normal. Whole exome sequencing identified a novel mutation in PIK3CD (NM_005026), c.C719T, resulting in p.T240M. Western blot analysis of downstream AKT levels revealed increased basal phosphorylation, in line with gain-of-function mutations of PIK3CD. Conclusion: The novel missense mutation in PIK3CD occurs in the region encoding the Ras-binding domain (RBD) of p110δ, and likely alters the structural configuration of the domain. To date, pathogenic mutations targeting the RBD of p110δ have not yet been described. Our results expand on the genotypic spectrum of APDS. Statement of Novelty: We describe a novel mutation in the Ras-binding domain of PIK3CD leading to a presentation of recurrent sinopulmonary and soft tissue infections in the context of APDS.

IN VITRO EXPERIMENTAL REWIRING OF 4 NEUTROPHILIC GRANULOCYTE SUBSETS FROM THE PRO-INFLAMMATORY TO THE ANTI-INFLAMMATORY PHENOTYPE IN CHILDREN WITH SURGICAL PURULENT INFECTION OF SOFT TISSUE

Treatment of young children with atypical or recurrent purulent soft tissue infections (PSTD) that do not respond well to surgery and antibiotics is most challenging. PSTD occurs against the background of impaired functioning of the immune system and, first of all, the system of neutrophilic granulocytes (NG). The vector effect of immunotropic therapy on a specific NG subsets may allow the correction of NG dysfunctions without compromising host protection, including strategies to enhance, inhibit or restore their functions.The aim of study: to evaluate in vitro the modulating effects of arginyl-alpha-aspartyl-lysyl-valyl-tyrosyl-arginine (HP) on the transformed phenotype of 4 NG subsets, as well as on the functional activity of NG in children with purulent-inflammatory soft tissue diseases.We studied samples of peripheral blood (PB) from young children 2-4 years old: 17 children with atypical acute PSTD and 10 apparently healthy children. At stage I, a comparative assessment of the content and phenotype of 4 NG subsets CD16+CD62L+СD63- , CD16+CD62L+СD63+, СD64- CD16+CD32+CD11b+, СD64+CD16+CD32+CD11b+, phagocytic and microbicidal functions of NG was carried out. At stage II, the in vitro system determined the effects of HP on NG in children with PSTD according to the studied parameters. By the method of flow cytometry (FC500 “Beckman Coulter” (USA), conjugates of MkAT “Beckman Coulter International S.A.” (France)), the relative number of NGs of the studied subsets and the density of receptor expression (MFI) were determined. To assess the phagocytic function of NG a microbiological method was used to assess the completeness of phagocytosis with S. aureus (strain 209). The activity of NG NADPH oxidase was investigated in the NBT-spontaneous test (NBTsp.) and in the in vitro NBT-induced test (NBTind.). A comparative study of PB samples from conventionally healthy children and children with PSTD made it possible to identify various variants of transformation of the phenotype of the studied NG subsets, associated with defects in their functional activity. In the in vitro system the effects of HP were demonstrated, manifested by a decrease in the amount of CD16+CD62L+CD63+NG and an increase in CD16+CD62L+CD63- NG, modulation of the negatively altered phenotype of subsets CD64- CD32+CD16+CD11b+NG and CD64+CD32+CD16+CD11b+NG, aimed at restoring phagocytic function and maintaining the tension of NADPH oxidases.As a result of the study it was found the immunomodulatory effects of HP, which is manifested in the reorientation of NG from the pro-inflammatory phenotype to the anti-inflammatory one, which can be used in the future when creating personalized targeted immunotherapy aimed at correcting defective functioning NG in early children, suffering from PSTD.

Comparative Effectiveness Study of Home-Based Interventions to Prevent CA-MRSA Infection Recurrence.

Recurrent skin and soft tissue infections (SSTI) caused by Community-Associated Methicillin-Resistant Staphylococcus aureus (CA-MRSA) or Methicillin-Sensitive Staphylococcus aureus (CA-MSSA) present treatment challenges. This community-based trial examined the effectiveness of an evidence-based intervention (CDC Guidelines, topical decolonization, surface decontamination) to reduce SSTI recurrence, mitigate household contamination/transmission, and improve patient-reported outcomes. Participants (n = 186) were individuals with confirmed MRSA(+)/MSSA(+) SSTIs and their household members. During home visits; Community Health Workers/Promotoras provided hygiene instructions; a five-day supply of nasal mupirocin; chlorhexidine for body cleansing; and household disinfecting wipes (Experimental; EXP) or Usual Care Control (UC CON) pamphlets. Primary outcome was six-month SSTI recurrence from electronic health records (EHR). Home visits (months 0; 3) and telephone assessments (months 0; 1; 6) collected self-report data. Index patients and participating household members provided surveillance culture swabs. Secondary outcomes included household surface contamination; household member colonization and transmission; quality of life; and satisfaction with care. There were no significant differences in SSTI recurrence between EXP and UC in the intent-to-treat cohort (n = 186) or the enrolled cohort (n = 119). EXP participants showed reduced but non-significant colonization rates. EXP and UC did not differ in household member transmission, contaminated surfaces, or patient-reported outcomes. This intervention did not reduce clinician-reported MRSA/MSSA SSTI recurrence. Taken together with other recent studies that employed more intensive decolonization protocols, it is possible that a promotora-delivered intervention instructing treatment for a longer or repetitive duration may be effective and should be examined by future studies.

A cutaneous tuberculosis mimic presented with recurrent soft tissue infection: A case report

Recurrent cellulitis is one of the cutaneous tuberculosis mimickers. As the skin lesion can mimic other skin diseases, the diagnosis can easily be missed especially in immunocompetent patients without any other risk factors. We present a case of a 62-year-old lady with history of right hand extensor tenosynovitis presented with right hand and forearm swelling and pain, associated with fever. Clinically, her right hand and forearm were erythematous with a small nodule at the right elbow. She was treated for recurrent right upper limb cellulitis and thrombophlebitis complicated by septic shock needing several courses of antibiotics. However, she did not show any significant response to the treatment. Multiple septics work up were carried out and all were negative, except aspiration of her right elbow nodule was positive for Mycobacterium tuberculosis. Anti-tuberculous treatment was started but unfortunately, she succumbed due to nosocomial infection.

Skin infections due to Panton-Valentine leukocidin (PVL)-producing S. aureus-Cost effectiveness of outpatient treatment.

IntroductionSkin and soft tissue infections (SSTI) caused by Panton-Valentine leukocidin (PVL)-producing strains of Staphylococcus aureus (PVL-SA) are associated with recurrent skin abscesses. Secondary prevention, in conjunction with primary treatment of the infection, focuses on topical decolonization. Topical decolonization is a standard procedure in cases of recurrent PVL-SA skin infections and is recommended in international guidelines. However, this outpatient treatment is often not fully reimbursed by health insurance providers, which may interfere with successful PVL-SA decolonization.AimOur goal was to estimate the cost effectiveness of outpatient decolonization of patients with recurrent PVL-SA skin infections. We calculated the average cost of treatment for PVL-SA per outpatient decolonization procedure as well as per in-hospital stay.MethodsThe study was conducted between 2014 and 2018 at a German tertiary care university hospital. The cohort analyzed was obtained from the hospital’s microbiology laboratory database. Data on medical costs, DRG-based diagnoses, and ICD-10 patient data was obtained from the hospital’s financial controlling department. We calculated the average cost of treatment for patients admitted for treatment of PVL-SA induced skin infections. The cost of outpatient treatment is based on the German regulations of drug prices for prescription drugs.ResultsWe analyzed a total of n = 466 swabs from n = 411 patients with recurrent skin infections suspected of carrying PVL-SA. PVL-SA was detected in 61.3% of all patients included in the study. Of those isolates, 80.6% were methicillin-susceptible, 19.4% methicillin-resistant. 89.8% of all patients were treated as outpatients. In 73.0% of inpatients colonized with PVL-SA the main diagnosis was SSTI. The median length of stay was 5.5 days for inpatients colonized with PVL-SA whose main diagnosis SSTI; the average cost was €2,283. The estimated costs per decolonization procedure in outpatients ranged from €50-€110, depending on the products used.ConclusionOur data shows that outpatient decolonization offers a highly cost-effective secondary prevention strategy, which may prevent costly inpatient treatments. Therefore, health insurance companies should consider providing coverage of outpatient treatment of recurrent PVL-SA skin and soft tissue infections.

Recurrent soft tissue infections associated with complex regional pain syndrome type ll: Reports of two unusual cases

Complex Regional Pain Syndrome (CRPS) (Synonyms: Reflex Sympathetic Dystrophy, Causalgia, Sudeck’s atrophy, Algodystrophy) is a chronic neurological condition, usually involving the limbs, that is characterized by severe pain along with sensory, autonomic, motor and trophic involvement. CRPS type ll is when there is an identifiable preceding event causing nerve damage. We present 2 unusual cases: 1. spontaneous bleeding from left leg associated with recurrent infections 2. a calcified mass in abdominal wall with recurrent infections. Recurrent soft tissue infections are rare in CRPS. Both presentations were unique.

Panton-valentine leukocidin staphylococcus causing necrotising pneumonia in a young male

Panton–Valentine leukocidin (PVL) is among one of the many toxins associated with Staphylococcus aureus infection. It commonly causes recurrent skin and soft tissue infections (SSTIs), but can sometimes be associated with severe invasive infections, including necrotising haemorrhagic pneumonia in otherwise healthy young people. Here we report a case of young male patient who presented with community acquired pneumonia that very rapidly progressed to necrotising haemorrhagic pneumonia leading to septic shock with multi-organ failure. His chest imaging showed extensive right sided cavitatory pneumonia &amp; his bronchial washings confirmed the presence of PVL positive Staph aureus. He was managed in Intensive care where he was resuscitated with organs support along with broad spectrum antibiotics. He later developed renal impairment needing renal replacement therapy. Patient gradually showed clinical signs of improvement after prolonged ICU admission. He was later stepped down to the Respiratory ward following improvement in clinical condition. Hence medical physicians need to know about Panton–Valentine leukocidin (PVL) producing staphylococcus aureus as early detection and treatment can save lives of patients.

AML-360: The Coexistence of Hyperimmunoglobulin E Syndrome and Myelodysplastic Syndrome

Context Hyperimmunoglobulin E syndrome (Job Syndrome) is one of the primary immunodeficiency syndromes and is generally inherited in an autosomal dominant fashion. This syndrome is characterized by elevation of serum immunoglobulin E level, chronic eczema, recurrent sinusitis and pneumonia, tendency for recurrent pyogenic infection, and soft tissue infections such as large abscesses. This disorder is associated with an increased risk for malignancies, especially lymphomas. Here, we report of a 45-year-old male with hyper-IgE syndrome who developed MDS transformed AML. Patient The patient had multiple erythematous papules and nodules with ulcerations on his face, left forearm, and legs. He had pancytopenia. Bone aspiration and biopsy were performed, which confirmed diagnosis of myelodysplastic syndrome with increased blasts. After 3+7 (idarubicin+cytarabine) induction chemotherapy, he had recurrent pneumonia, pre-septal cellulitis, a breast abscess, and catheter infection. We found elevated IgE. He was diagnosed with Hyperimmunoglobulin E syndrome. After receiving two cycles of azacytidine, he still had refractory disease. He was shifted to decitabine and venetoclax. He required intensive care unit hospitalization for gastrointestinal bleeding but passed away. Conclusion As in our case, hyperimmunoglobulin E syndrome should be considered in patients with hematological malignancies and recurrent soft tissue infections.

Impact of medications for opioid use disorder among persons hospitalized for drug use-associated skin and soft tissue infections

BackgroundSkin and soft tissue infections (SSTI) are common complications of injection drug use. We aimed to determine if rehospitalization and recurrent SSTI differ among persons with opioid use disorder (OUD) hospitalized for SSTI who are initiated on MOUD within 30 days of discharge and those who are not. MethodsWe performed a retrospective analysis of commercially insured adults aged 18 years and older in the U.S. with OUD and hospitalization for injection-related SSTI from 2010–2017. The primary exposure was initiation of MOUD in the 30 days following hospitalization for SSTI. The primary outcomes included 30-day and 1-year 1) all-cause rehospitalization and 2) recurrent SSTI. We calculated the incidence rates for the two groups: MOUD group and no MOUD group for the primary outcomes. We developed Cox models to determine if rehospitalization and recurrent SSTI differ between the two groups. ResultsOnly 5.5 % (357/6538) of people received MOUD in the month following their index SSTI hospitalization. 30-day rehospitalization incidence was higher in the MOUD group compared to no MOUD (35.9 vs 27.5 per 100 person-30 days) and one-year SSTI recurrence was lower (10.3 vs 18.7 per 100 person-years). In multivariable modeling, the MOUD group remained at significantly higher risk of 30-day rehospitalization compared to the no MOUD group and at lower risk for one-year SSTI recurrence. ConclusionsMOUD receipt following SSTI hospitalization decreases risk of recurrent SSTI among persons with OUD. Further expansion of these in-hospital services could provide an effective tool in the U.S. response to the opioid epidemic.

Lymphedema: Conventional to Cutting Edge Treatment.

Lymphedema of the extremities related to oncologic therapies such as cancer surgery, radiation therapy, and chemotherapy is a major long-term cause of morbidity for cancer patients. Both nonsurgical and surgical management strategies have been developed. The goals of these therapies are to achieve volume reduction of the affected extremity, a reduction in patient symptoms, and a reduction in associated morbidities such as recurrent soft-tissue infections. In this article, we review both nonsurgical and surgical management strategies. Traditional surgical therapy has focused on more ablative techniques such as the Charles procedure and suction-assisted lipectomy/liposuction. However, newer more physiologic surgical methods such as lymphovenous anastomoses and vascularized lymph node transfers have become a more common treatment modality for the management of this complex problem.

Morphea (Localized Scleroderma) Presenting With Recurrent Skin and Soft Tissue Infections: A Diagnostic Dilemma

Morphea or localized scleroderma is reported to be triggered through diverse stimuli. We present a case of morphea that presented as a non-healing wound with superimposed methicillin-sensitive Staphylococcus aureus (MSSA) infection. In our case, morphea was thought to have been potentially triggered by a post-surgical infection. We discuss the potential infectious triggers and common infections that may confound the diagnosis.