Resolution Of Ulcers Research Articles

Clinical tolerance of untreated reflux after iliac vein stent placement

BackgroundWe have recently demonstrated in a large patient cohort that the prevalence and severity of reflux will improve in most limbs after stenting and that most limbs will not develop new-onset reflux. In the present report, we have focused on the long-term clinical outcomes associated with untreated reflux in the same patient cohort who had undergone iliofemoral venous stenting without correction of residual reflux. MethodsThe clinical outcomes data from 1379 limbs treated with only iliac vein stenting without correction of superficial or deep reflux from 1997 to 2018 were analyzed (23-year follow-up period). Of the 1379 limbs, 632 (46%) had had preexisting reflux before stenting and 747 (54%) had did not. The reflux data (reflux segmental score, air plethysmography, ambulatory venous pressure) for these patients have been previously reported in detail. The subsets were compared perioperatively with each other using the following variables: grade of swelling, visual analog scale for pain score, venous clinical severity score, venous stasis dermatitis, ulceration, and quality of life measures. ResultsBoth groups demonstrated improvements in the venous clinical severity score, grade of swelling, visual analog scale score, and quality of life. No differences were found in ulcer healing (5% vs 3% for limbs with and without prestent reflux, respectively) and resolution of dermatitis (6% vs 5% for limbs with and without prestent reflux, respectively) between the two groups. Of the 632 limbs with preexisting reflux, 218 (34%) had had axial reflux and 414 had had nonaxial reflux (66%). The clinical outcomes were similar between the two groups. Using a multisegment reflux score, the limbs with prestent reflux (n = 632) were divided into two groups. A segmental score of ≥3 indicated severe reflux and a score of <3 indicated moderate reflux. Of these 632 limbs, 161 (25%) had severe reflux and 471 (75%) had moderate reflux. The two groups demonstrated similar outcomes for most clinical parameters. The post-thrombotic limbs and nonthrombotic limbs also showed similar outcomes. ConclusionsThe long-term follow-up of patients after iliac vein stenting showed that uncorrected reflux is well tolerated by most patients across most clinical measures.

THE RANDOMIZED, DOUBLE-BLIND, MULTICENTER, PLACEBO-CONTROLLED PHASE 3 RESOLVE TRIAL INVESTIGATING THE EFFICACY OF VOXELOTOR WITH STANDARD OF CARE IN THE RESOLUTION OF LEG ULCERS IN PATIENTS WITH SICKLE CELL DISEASE

In sickle cell disease (SCD), polymerization of deoxygenated sickle hemoglobin (HbS) is the major pathological process that leads to red blood cell sickling and hemolysis. In addition to the major complications of SCD, including hemolytic anemia, inflammation, and vascular occlusion, patients often experience secondary complications such as stroke, organ damage, shortened lifespan, and painful and debilitating skin ulcers. Given the lack of registries and large prospective studies examining leg ulcers, their prevalence among individuals with SCD is likely underestimated but varies widely by geographic region: 43% in Brazil, 30% in Jamaica, 27% in Nigeria, 19% in Ghana, 13% in Sierra Leone, 8% in Saudi Arabia, and 1% to 5% in the US. Voxelotor, a HbS polymerization inhibitor that targets the underlying SCD pathology, is approved in the US for treatment of SCD in patients aged ≥4 years and in the UK, EU, and UAE for patients aged ≥12 years. In a post hoc analysis of voxelotor-treated patients from the pivotal HOPE trial (NCT03036813), leg ulcers resolved within 24 weeks in 10 out of 14 patients and improved or resolved by week 72 in 13 out of 14 patients. RESOLVE is an ongoing phase 3, randomized, double-blind, placebo-controlled, multicenter trial investigating the efficacy of voxelotor with standard of care (SOC) in the resolution of leg ulcers in patients with SCD. The study will be conducted at sites in Brazil (9), Nigeria (7), and Kenya (5). Target study enrollment is 80 patients aged ≥ 12 years with a confirmed diagnosis of SCD (HbSS or HbSβ 0 genotype) and ≥1 cutaneous ulcer on the lower extremity (leg, ankle, or dorsum of foot) that meets the following criteria: ≥ 2 weeks’ and < 6 months’ duration at screening and >2 cm 2 in area before randomization. After a 2-week run-in period, participants are randomized 1:1 to receive once-daily oral voxelotor 1500 mg or placebo in addition to SOC for 12 weeks. After the randomized treatment period, all participants enter an open-label treatment period and receive voxelotor 1500 mg plus SOC for an additional 12 weeks. Participants will have the option to enroll in a separate open-label extension study after completing the 24-week treatment period. All study sites in Brazil will be activated by the end of 2022, with the first patient evaluation in Brazil anticipated to occur in the first week of December 2022. The primary objective of this study—to assess the efficacy of voxelotor plus SOC compared with placebo plus SOC in healing leg ulcers—is measured by the proportion of patients with resolution of target ulcer(s) in each treatment group by week 12. Key secondary endpoints include days to resolution of target ulcer(s) up to week 12, change from baseline in total surface area of target ulcer(s) at week 12, and incidence of new ulcers by week 12. Exploratory analyses include correlation of target ulcer(s) healing with change in hemoglobin and hemolytic parameters. The study will also assess patient-reported outcome measures, including health-related quality of life and pain. Findings from a post hoc analysis of participants with leg ulcers in the HOPE trial suggest that voxelotor may be an effective treatment for leg ulcers in patients with SCD. Voxelotor directly targets the underlying mechanism of disease (namely HbS polymerization) and may have a therapeutic effect on the clinical complications of SCD associated with anemia and hemolysis, including leg ulcers. Results from this study will advance our understanding of the potential effects of voxelotor on leg ulcers in patients with SCD in global populations.

ATYPICAL PRESENTATION OF GRANULOMATOUS INFLAMMATION

ATYPICAL PRESENTATION OF GRANULOMATOUS INFLAMMATION

S3546 Transcatheter Arterial Radioembolization (TARE)-Induced Gastric Ulcer in an Excluded Stomach After Roux-en-Y Gastric Bypass

Introduction: Transcatheter arterial radioembolization (TARE) is a commonly utilized locoregional treatment for hepatocellular carcinoma (HCC) and confers lower risk of hepatic ischemia owing to the safety profile of Yttrium-90 glass microspheres used in TARE. However, peptic ulcer disease occurs in 1-5% of TARE treatments. Here we describe a unique case of a TARE-induced gastric ulcer in an excluded stomach after Roux-en-Y gastric bypass (RYGB). Case Description/Methods: 70-year-old male with RYGB in 2012 and hepatitis C/nonalcoholic steatohepatitis cirrhosis complicated by HCC treated with TARE and liver transplant six months earlier was evaluated for melena. Esophagogastroduodenoscopy, colonoscopy, and an antegrade double balloon-assisted enteroscopy (DBE) found no obvious source. The excluded stomach could not be reached during DBE. Due to continued melena and transfusion dependence, he underwent a laparoscopic assisted gastroduodenoscopy (GD) to evaluate the excluded stomach. This revealed a 3 cm gastric ulcer in the pre-pylorus with biopsies showing radiation induced ulcer without evidence of malignancy, viral infection, or helicobacter pylori (Figure 1a). Gastrostomy tube (G-tube) access was maintained in the excluded stomach to administer twice daily liquid proton pump inhibitor (PPI) via the G-tube. Repeat GD after eight weeks of treatment showed a well-healing gastric ulcer (Figure 1b). Patient’s hemoglobin also stabilized and had no further transfusion requirement. Discussion: Gastric ulcers in the excluded stomach after RYGB are rare, especially 10 years after surgery. To our knowledge, this is the first reported incident of radiation induced ulcer in an excluded stomach. For treatment, G-tube access was maintained to the excluded stomach for administration of liquid PPI with excellent ulcer healing and resolution of melena and anemia. This treatment approach was selected based on previous data demonstrating benefit of open capsule PPI to treat marginal ulcers following RYGB1. Open capsule PPI administration is thought to enhance healing in these cases as this bypasses the need for capsular breakdown in the stomach for absorption, but it is unclear if a similar mechanism is true for an excluded stomach and warrants further studies to better understand its pharmacokinetics. This case highlights a unique case of a TARE-induced gastric ulcer in the RYGB excluded stomach that was successfully treated with liquid PPI.Figure 1.: (a) High power view of the ulcer slough shows fibrosis with prominent atypical fibroblasts consistent with radiation enteritis (H&E, 400×) (b) Repeat gastroduodenoscopy showing healing ulcer.

P-059: TRIAL IN PROGRESS: THE RANDOMIZED, DOUBLE-BLIND, MULTICENTER, PLACEBO-CONTROLLED PHASE 3 RESOLVE TRIAL INVESTIGATING THE EFFICACY OF VOXELOTOR WITH STANDARD OF CARE IN THE RESOLUTION OF LEG ULCERS IN PATIENTS WITH SICKLE CELL DISEASE

Purpose: Sickle cell disease (SCD) is a heritable blood disorder caused by a point mutation in the β-globin gene. Polymerization of deoxygenated mutated hemoglobin is the major molecular process in SCD pathogenesis that leads to red blood cell sickling and hemolysis. In addition to the major complications of SCD—hemolytic anemia, inflammation, and vascular occlusion—patients often experience secondary complications such as stroke, organ damage, shortened lifespan, and painful and debilitating skin ulcers. The prevalence of leg ulcers among people with SCD is likely underestimated, given the lack of registries and large prospective studies examining this complication. Current estimates of leg ulcers vary widely by geographic region: 43% in Brazil, 30% in Jamaica, 27% in Nigeria, 19% in Ghana, 13% in Sierra Leone, 8% in Saudi Arabia, and 1%-5% in the US. Among Americans with SCD, an estimated 14%-18% may develop leg ulcers. Voxelotor, a sickle hemoglobin polymerization inhibitor, is approved in the US for the treatment of SCD in adults and pediatric patients aged ≥4 years and in the EU for the treatment of hemolytic anemia due to SCD in adults and pediatric patients aged ≥12 years as a monotherapy or in combination with hydroxycarbamide. In a post hoc analysis of voxelotor-treated patients from the phase 3 HOPE study (NCT03036813), leg ulcers resolved within 24 weeks in 10 out of 14 patients, and leg ulcers improved or resolved in 13 out of 14 patients by week 72. Materials and methods: RESOLVE is an ongoing phase 3, randomized, double-blind, placebo-controlled, multicenter trial investigating the efficacy of voxelotor with standard of care (SOC) in the resolution of leg ulcers in patients with SCD. Target enrollment is 80 patients from Nigeria, Kenya, and Brazil with a confirmed diagnosis of SCD (HbSS or HbSβ0 genotype), aged ≥12 years, and with ≥1 cutaneous ulcer on the lower extremity (leg, ankle, or dorsum of foot) that meets the following criteria: ≥2 weeks’ and <6 months’ duration at screening and >2 cm2 in area before randomization. After a 2-week run-in period, participants are randomized 1:1 to receive once-daily oral voxelotor 1500 mg or placebo in addition to SOC for 12 weeks. After the randomized treatment period, all participants receive open-label voxelotor 1500 mg plus SOC for 12 weeks (Figure). Results: The primary objective of the study is to assess the efficacy of voxelotor plus SOC compared with placebo plus SOC on leg ulcer healing, measured by the proportion of patients with resolution of target ulcer(s) in each treatment group by week 12. Key secondary endpoints include days to resolution of target ulcer(s) up to week 12, change from baseline in total surface area of target ulcer(s) at week 12, and incidence of new ulcers by week 12. Conclusion: Results from this study will further guide clinicians and patients regarding the clinical use of voxelotor for the treatment of leg ulcers in patients with SCD. Participants will have the option to enroll in a separate open-label extension study after the 24-week treatment period.Figure. RESOLVE Study Design, Population, and Timeline J. DOSS declares a conflict of interest: Stock shareholder: Global Blood Therapeutics, Roche

The value of administering intravenous antibiotics during haemodialysis in the treatment of diabetic foot infections.

People with diabetes who are on haemodialysis (HD) are at a high risk of diabetic foot infections (DFI) and related complications. We explored the value of treating DFI with intravenous (IV) antibiotics during HD. This was an observational study of consecutively treated patients with DFIs with IV antibiotics during HD. Data collected included baseline characteristics, IV antibiotics used, details of multidisciplinary interventions and DFI treatment outcome. A cohort of 11 patients, mean (±standard deviation) age 62.4±12.7 years, had 15 episodes of treatment with IV antibiotics during HD. Of the patients, six (54.5%) were male and nine (81.8%) had type 2 diabetes. The estimated mean glomerular filtration rate (eGFR) was 11.4±3.9ml/minute. All patients had infected foot ulceration, soft tissue infection, six (54.5%) patients had osteomyelitis, and two (18.2%) had wet gangrene. The commonest IV antibiotic used was vancomycin (10/15 episodes, 66.7%). Other IV antibiotics used were daptomycin and meropenem. In three episodes, oral ciprofloxacin was used with IV antibiotics. The mean duration of antibiotic treatment was 9.2±4.9 weeks. Of the episodes, 11 (73.3%) were treated successfully with IV antibiotics alone and two (13.3%) episodes required minor surgical debridement/amputation. Some 10 (90.9%) members of the cohort had peripheral arterial disease and of those, five (50%) underwent angioplasty during IV antibiotic treatment. HD provides a good opportunity for treatment with IV antibiotics in DFI. This mode of administration of IV antibiotics, along with multidisciplinary intervention, is associated with ulcer healing and resolution of infection in over three-quarters of patients with DFI. The authors have no conflicts of interest to declare.

Amoebicidal effect of Allium cepa against Allovahlkampfia spelaea: A keratitis model

Allovahlkampfia spelaea (A. spelaea) is a free-living amoeba, proved to cause Acanthamoeba-like keratitis with quite difficult treatment. This study aimed to evaluate the amoebicidal effect of Allium cepa (A. cepa) on A. spelaea trophozoites and cysts both in vitro and in vivo using Chinchilla rabbits as an experimental model of this type of keratitis. Chemical constituents of the aqueous extract of A. cepa were identified using Liquid Chromatography-mass Spectrometry (LC-MS). In vitro, A. cepa showed a significant inhibitory effect on trophozoites and cysts compared to the reference drug, chlorhexidine (CHX) as well as the non-treated control (P < 0.05) with statistically different effectiveness in terms of treatment durations and concentrations. No cytotoxic effect of A. cepa on corneal cell line was found even at high concentrations (32 mg/ml) using agar diffusion method. The in vivo results confirmed the efficacy of A. cepa where the extract enhanced keratitis healing with complete resolution of corneal ulcers in 80% of the infected animals by day 14 (post infection)pi compared to 70% recovery with CHX after 20 treatment days. The therapeutic effect was also approved at histological, immune-histochemical, and parasitological levels. Our findings support the potential use of A. cepa as an effective agent against A. spelaea keratitis.

VORICONAZOLE-ASSOCIATED MUCOSAL ULCERATION AFTER LUNG TRANSPLANT

TYPE: Case Report TOPIC: Transplantation INTRODUCTION: Colonization and isolation of Aspergillus from bronchial specimens predisposes lung transplant (LTx) recipients to airway anastomotic complications and allograft rejection. Post-LTx antifungal prophylaxis with voriconazole has been associated with cutaneous malignancies. We report a case of voriconazole-associated mucosal ulceration in an LTx recipient that improved upon drug discontinuation. CASE PRESENTATION: A 56-year-old LTx recipient (November 2020) presented to the clinic in January 2021 for painful oral and anal ulcers. He was managed with reduced maintenance immunosuppression, filgrastim, lidocaine-diphenhydramine-corticosteroid oral rinse, and topical nitroglycerin-nystatin ointments without relief. He returned to the emergency department in February for worsening pain, facial swelling, inability to open mouth, and difficult defecation. Inpatient evaluation demonstrated neutropenia (0.8/μL), lymphopenia (0.5/μL), and elevated inflammatory markers [ESR: 119 mm/h; CRP: 123.2 mg/L; procalcitonin: 0.14 ng/mL]. However, blood culture, serology for Epstein-Barr virus, herpes simplex virus, cytomegalovirus, head-neck and chest imaging, esophagogastroduodenoscopy, perianal punch biopsy, and anal canal incisional biopsy were unremarkable. Importantly, serum voriconazole level was elevated (7.2 μg/mL). Discontinuation of voriconazole led to relief in symptoms and discharge. On clinic follow-up, he endorsed complete resolution of ulcers. Of note, his antifungal prophylaxis was temporarily switched from isavuconazole to voriconazole in January. DISCUSSION: Voriconazole-induced photosensitivity and elevated plasma retinol levels may progress to cutaneous malignancies. In our patient, temporality of onset (one week) and resolution (within days) of mucosal ulceration with voriconazole discontinuation suggest an association. No residual scarring or recurrence was observed. CONCLUSIONS: Physicians must be mindful of dermatologic adverse events of voriconazole in LTx recipients. DISCLOSURE: Nothing to declare. KEYWORD: Lung transplantation

Cytologic detection of Simonsiella‐like bacteria suggesting oral contamination in cases of canine ulcerative keratitis

AbstractSimonsiella is a known oral commensal organism and has been identified as a part of the normal ocular microbiota in humans. This case series highlights three cases of canine ulcerative keratitis in which a mixed bacterial infection, including high numbers of Simonsiella spp. had been identified cytologically. All cases had episodes of oral contamination, either from licking the eye, licking the paws and rubbing the eye, or housemate(s) licking the eye. In two of three cases, ulcer resolution was observed within 3 weeks following initiation of broad‐spectrum topical antimicrobial therapy.

CMV Colitis Mimicking Crohn’s Disease in a Patient with CLL: A Case Report

Background: Cytomegalovirus (CMV) infections are common, especially in immunocompromised patients. These infections are usually asymptomatic but can become symptomatic in immunocompromised individuals, with colitis being the second most common presentation of end-organ disease. CMV colitis can mimic Inflammatory Bowel Disease (IBD) or cause an IBD flare, thus making the diagnosis challenging. Case Report: We describe the case of a 69-year-old male known to have Chronic Lymphocytic Leukemia (CLL) maintained in remission on venetoclax, a BCL-2 inhibitor. The patient was recently started on mesalamine and steroids after a Crohn’s Disease (CD) diagnosis three weeks before presentation. The patient presented with bloody diarrhea and abdominal pain. His workup included a colonoscopy that showed skip lesions (diffuse ulcerated lesions separated by areas of normal mucosa), a characteristic of CD. Ileal and colonic biopsies were sent for Polymerase Chain Reaction (PCR) of CMV and turned out positive. Therefore, the patient was diagnosed with CD with superimposed CMV colitis. We started the patient on ganciclovir. Three months later, a repeat colonoscopy revealed complete resolution of mucosal ulcerations, practically changing the diagnosis to an isolated CMV colitis mimicking CD. Conclusion: An isolated CMV colitis can mimic CD, and physicians must consider this entity in their differential diagnosis. This case is additionally remarkable because CLL and the use of a BCL-2 inhibitor usually have a protective role against CMV disease, but this was not the case for our patient.

Medical management and resolution of perinatal bilateral exophthalmia and secondary corneal ulcers in an Antillean manatee (Trichechus manatus manatus) neonate from Puerto Rico

AbstractObjectiveTo present a novel case of perinatal bilateral exophthalmos and corneal ulcers in a neonate Antillean manatee and describe the medical treatment that led to the resolution of the observed clinical signs and vision restoration.Animal studiedA manatee stranded alone in Puerto Rico on July 5, 2020.ResultsThe manatee was found in critical condition with pronounced exophthalmos, lagophthalmos, and corneal opacification of both eyes (OU). Vision impairment was evident due to the lack of ocular menace reflex and bumping into the tank's walls. Biomicroscopy revealed conjunctival hyperemia and chemosis, limited third eyelid movement, but had viscous tears present OU. Dense, full‐thickness, white to cream‐colored cellular infiltrates affected 70% of the cornea with peripheral active vascularization OU. Rubeosis iridis was also present OU. Treatment consisted of supportive medical management, including nutritional support and topical treatment for ulcerative keratitis. Resolution of the corneal ulcers and functional vision were achieved after 6 weeks of therapy. Currently, bilateral, mild, intermittent exophthalmos is observed with no adverse clinical signs, and the calf is in good health.ConclusionsThe extent of bilateral corneal disease on a neonatal calf may be a result of an intrauterine infection or possible trauma at or right after birth. While the latter may have led to exophthalmia and consequent corneal disease, the exact cause could not be determined. Supportive therapy and medical management of infectious keratitis were successful and led to vision recovery. This is the first report of ocular pathology in a neonatal manatee.

Comparative analysis of endovenous laser ablation versus ultrasound-guided foam sclerotherapy for the treatment of venous leg ulcers.

Endovenous thermal and non‐thermal therapeutic approaches have become standard of care for the treatment of venous insufficiency. However, comparative studies on its use in the population of venous leg ulcer patients are scarce. The present study aimed at a comparison of the efficacy of endovenous laser ablation (EVLA) and ultrasound‐guided foam sclerotherapy (UGFS) for the treatment of venous leg ulcers (VUs). We retrospectively analyzed patient records of 68 patients with active VUs (C6 of the CEAP‐classification), who underwent EVLA (n = 33) or UGFS (n = 35) between January 2001 and January 2021. In 68 patients, 97 venous segments (GSV: 43, SSV: 17, NSV: 37) were treated. Ulcer surface area at initial presentation did not differ significantly between both treatment groups (EVLA: 7.7 ± 10.7 vs. UGFS: 8.5 ± 16.3 cm2; p = 0.73). No significant difference regarding patient characteristics was found, with the exception of age, as patients receiving UGFS treatment were significantly older (EVLA: 61 ± 17 vs. UGFS: 70 ± 14 years; p = 0.018). The rate of ulcer resolution was not significantly different between EVLA and UGFS groups (97.0% vs. 85.7%; p = 0.20). Also, the mean time to complete ulcer healing after endovenous intervention was comparable (EVLA: 59 ± 37 vs. UGFS: 63 ± 41 days; p = 0.68). However, the relapse rate was significantly higher for UGFS than for EVLA treated patients (31.4% vs. 3.0%; p = 0.002). Taken together, rates of ulcer resolution and ulcer healing time after endovenous intervention were comparable between both treatment modalities. Nevertheless, a significantly higher relapse rate was observed in UGFS treated patients.

Efficacy and safety of intravenous immunoglobulin for treating refractory livedoid vasculopathy: a systematic review.

Introduction:Intravenous immunoglobulin (IVIG) was reported to be the third most used monotherapy in livedoid vasculopathy (LV). There is currently a lack of randomized controlled clinical trials and no standardized therapeutic regimen for IVIG therapy in LV.Methods:We performed a systematic review of the efficacy and safety of IVIG in treating patients with LV using PubMed, Cochrane, and Embase databases.Results:Eighty LV patients from 17 articles were included, receiving IVIG therapy at a dose of 1–2.1 g/kg body weight every 4 weeks. The effective rate of IVIG therapy in LV patients was 95% (76/80) in published studies, showing a good clinical response for resolution of pain, skin ulcerations, and neurological symptoms, and reducing the dependence on glucocorticoids and immunosuppressive agents. IVIG therapy was well tolerated, and no severe adverse events were observed.Conclusion:Overall, to a certain degree, IVIG is probably a safe and effective treatment alternative for refractory LV patients, which still need to be confirmed by large-scale randomized controlled clinical trials.

A Study Protocol for Assessing the Effect of Diode Green Photocoagulation with Rose Bengal in Progressive Infectious Keratitis

Background: Infectious keratitis manifested as corneal ulcer can result in formation of pus in corneal tissue. The incidence has increased in recent years due to overuse of steroids. Infectious keratitis is the most common cause of blindness in India. Rose Bengal proves to be a promising option to treat this condition. Rose Bengal is topical ophthalmic dye which is mildly toxic. It is absorbed by damaged epithelial cells, mucus and fibrous cells. This stain is available in the form of 1% solution or impregnated filter strips. This study aims to assess the duration of resolution of corneal ulcer after Rose Bengal photodynamic therapy.&#x0D; Methodology: This will be an experimental study carried out at ophthalmology department of AVBRH, Wardha. Total 55 cases will be enrolled and examined on daily basis for one week. Pachymetry and specular microscopy will be done before Rose Bengal Photodynamic Therapy and at the end of three months of treatment.&#x0D; Results: Resistant infectious keratitis is expected to show complete healing of epithelial defect after receiving photodynamic therapy with green diode laser.

Purpura Fulminans in a 20-Year-Old Female

&#x0D; &#x0D; &#x0D; A previously healthy 20-year-old female presented with extensive retiform purpura located at the face, upper and lower limbs, one week after an episode of acute tonsillitis. Despite the exuberance of the cutaneous findings and progression to skin necrosis she had no accompanying symptoms. Laboratory investigation revealed a heterozygous protein C mutation (exon 9, c.1332G&gt; C, p.Trp444Cys), accounting for a partial deficiency of this anticoagulant protein. The patient was started on broad spectrum antibiotics, anticoagulation and systemic corticosteroids, with no lesional progression and complete resolution of cutaneous ulceration within 6 months.&#x0D; This is a singular case of purpura fulminans, since two different causative factors precipitated the events. The previous tonsillitis reported by the patient is significant, because the serum concentration of protein S may also decrease after an infectious event - post-infectious purpura fulminans. This case illustrates that purpura fulminans due to autoantibodies against protein S, although rare, should be considered, especially in the absence of a severe acute infection. It also illustrates how in a given patient different independent factors can act simultaneously, triggering potentially devastating clinical scenarios.&#x0D; &#x0D; &#x0D;

S2191 Endoscopic and Medical Management of Actinomycosis Infection at the Gastro-Jejunal Anastomosis After Subtotal Gastrectomy With Roux-en-Y Reconstruction Resolves Chronic Abdominal Pain

Introduction: Roux-en-Y gastric bypass surgery (RYGB) is one of the most common type of gastric surgeries performed worldwide. Chronic post-operative abdominal pain post RYGB occurs in up to 30% of patients. We present an 82-year-old female with chronic abdominal pain post RYGB caused by actinomycosis infection at gastrojejunal anastomosis associated with suture material. Case Description/Methods: An 82-year-old female presented with persistent epigastric abdominal pain following subtotal gastrectomy with Roux-en-Y reconstruction for stage 1 gastric adenocarcinoma. She reported chronic abdominal pain within a year of surgery. Imaging with CT abdomen/pelvis was unremarkable and EGD demonstrated a marginal ulcer. She was started on PPI but abdominal pain worsened, requiring multiple hospitalizations, repeated imaging and endoscopies over the next 5 years following surgery without an identified etiology for her ongoing abdominal pain. Repeat EGD at our center showed resolution of marginal ulcer and nodularity at the gastrojejunal anastomosis with associated suture material. Biopsies of the nodule demonstrated Actinomycosis infection with acute inflammatory exudate. She was started on amoxicillin and repeat EGD was performed with removal of suture material using endoscopic suture cutters. Repeat biopsy confirmed Actinomyces infection of the anastomosis as well as colonization of suture material. Antibiotics were continued for a total of six months and her abdominal pain completely resolved. Repeat EGD after completion of therapy demonstrated no evidence of actinomycosis infection at the anastomosis. Discussion: Actinomycosis infection following RYGB surgery is an uncommon source of post-operative chronic abdominal pain. In our case, increase in gastric pH after RYGB surgery due to anatomical changes and PPI usage as well as retained suture likely predisposed to this infection. There may have been a delay in diagnosis due to difficulty in visualizing the suture material on repeat EGD as it was located behind a fold of the anastomosis. This reinforces the recommendation for careful inspection of the post-RYGB anastomosis when evaluating chronic post-operative abdominal pain. Prior cases of intra-abdominal Actinomyces infection after RYGB required prolonged antibiotics for greater than 12 months or surgical intervention. To our knowledge, this is the first reported case of Actinomyces at the gastrojejunal anastomosis successfully treated with endoscopic foreign body removal and six months of antimicrobials.

Apremilast in a Japanese subgroup with Behçet's syndrome: Results from a Phase 3, randomised, double-blind, placebo-controlled study.

Apremilast efficacy and safety was assessed in a prespecified subgroup of Japanese patients with oral ulcers associated with Behçet's syndrome from a Phase 3 randomized, placebo-controlled, double-blind study of apremilast (RELIEF). The primary end point was area under the curve for number of oral ulcers during the 12-week placebo-controlled phase (AUCWk0-12). Key secondary end points were change from baseline in oral ulcer pain, complete oral ulcer resolution, and measures of disease activity and quality of life (QoL). Thirty-nine Japanese patients were randomised (apremilast 30 mg BID: n = 19; placebo: n = 20). Improvements at Week 12 were observed for apremilast vs. placebo in AUCWk0-12 for the number of oral ulcers (115.9 vs. 253.3; nominal P = 0.0168); 57.9% vs. 25.0% achieved complete oral ulcer resolution, 47.4% vs. 0.0% achieved oral ulcer resolution by Week 6 and maintained oral ulcer-free status for ≥6 additional weeks; mean change from baseline in BSAS was -10.5 vs. 0.5. Favourable effects were observed for apremilast vs. placebo in other secondary end points, including QoL. Clinical benefits were sustained over 28 weeks of continued apremilast treatment. Adverse events were consistent with apremilast's known safety profile. Apremilast reduced the number of oral ulcers and overall disease activity in this Japanese subgroup with Behçet's syndrome.

The impact of comorbidity identification on outcomes in patients with pyoderma gangrenosum: A retrospective cohort study of previously hospitalized patients

The impact of comorbidity identification on outcomes in patients with pyoderma gangrenosum: A retrospective cohort study of previously hospitalized patients

Inflammatory arthritis-associated pyoderma gangrenosum: a systematic review.

Pyoderma gangrenosum (PG) is a rare, rapidly progressive neutrophilic dermatosis commonly associated with systemic inflammatory diseases. We aimed to characterize the association of PG and inflammatory arthritis, as little is known outside of case reports and small cohort studies. We performed a systematic review in PubMed, EMBASE, and Scopus from inception to present using the terms arthritis and pyoderma gangrenosum. Patient demographics, clinical presentation, and treatment outcomes were recorded. Descriptive statistics and stratified analysis were used to compare factors of interest by type of arthritis. A total of 1399 articles were screened, and 129 patients with inflammatory arthritis and PG were included in the review. The most common types of arthritis were rheumatoid arthritis (RA) (50.4%), inflammatory bowel disease (IBD)-associated arthritis (10.9%), and psoriatic arthritis (8.5%). In the vast majority of cases, joint symptoms preceded PG, by a median of 10years (inter-quartile range [IQR] 5-16). Corticosteroid monotherapy and biologic therapies, used alone or in combination, resulted in improvement or complete resolution of ulcers 71.4% and 67.3% of the time, respectively. Within the latter, infliximab, adalimumab, and anakinra were most successful in inducing remission overall. RA and non-RA did not differ significantly in treatment success or healing time. This study shows that PG is frequently preceded by inflammatory arthritis, most commonly RA. Clinicians used a wide variety of treatment regimens with variable outcomes. While larger studies are needed to standardize the treatment of inflammatory arthritis-associated PG, this study suggests that in addition to systemic corticosteroids, biologic medications can be effective treatment options for these patients. • Inflammatory arthritis, most commonly rheumatoid arthritis, often precedes rather than follows pyoderma gangrenosum. • Other forms of arthritis associated with PG included IBD-associated arthritis and psoriatic arthritis. • Biologic therapies, such as infliximab, adalimumab, and anakinra, were largely successful in treating arthritis-associated pyoderma gangrenosum and may play an important role in corticosteroid-sparing therapy or in a maintenance regimen for this subset of patients. • The type of inflammatory arthritis associated with pyoderma gangrenosum may not be a helpful treatment guide as it was not significantly associated with treatment outcomes or healing time.

Bilateral Pseudomonas aeruginosa Keratitis in 7 Patients.

To report 7 patients (14 eyes) with bilateral Pseudomonas aeruginosa keratitis (PAK). Case records of patients with bilateral PAK were reviewed at a single academic medical center from April 2009 to December 2020. Seven patients aged 29 to 94 years presented with bilateral P. aeruginosa corneal ulcers. All patients were soft contact lens wearers except one elderly patient with a complex ocular history. Three patients wore specialty contact lens, including one cosmetic contact lens wearer, one multifocal contact lens wearer, and one extended-wear contact lens wearer. The remaining three patients were not overnight contact lens wearer but regularly showered in contact lens or used tap water for contact lens case cleaning. All patients presented with asymmetric disease, with visual acuity ranging from 20/20 to light perception. Ulcers were located centrally in 5 eyes (35.7%), diffusely over the entire cornea in 5 eyes (35.7%), temporally in 2 eyes (14.2%), and nasally in 1 eye (7.14%), and in 1 eye (8.3%), the ulcer location was not recorded. Corneal thinning was noted in 7 eyes (50%). Hypopyon was also noted in 7 eyes (50%). Two patients required procedures because of progressive stromal necrosis. All other patients were treated nonsurgically, with antibiotic drops, which resulted in ulcer resolution. Final visual acuity on last recorded follow-up ranged from 20/20 to no light perception. This is the largest case series of bilateral PAK, which occurred primarily in contact lens wearer. This case series reiterates the risk of contact lens infection related to poor hygiene.