Tuesday, September 29, 2009
Hidradenitis suppurativa
Hudavdelingen, Haukeland universitetssykehus, 5021 Bergen. etolaas@broadpark.no
BACKGROUND: Hidradenitis suppurativa is a chronic inflammatory skin disease characterized by recurrent tender nodules and boils, usually in the armpits and groins. Draining fistulas and hypertrophic scarring are hallmarks of more severe disease. The objective of this article is to review the clinical presentation, diagnostic considerations and treatment of the disease.
MATERIAL AND METHODS: The article is based on a non-systematic literature search in PubMed, review of dermatology textbooks and the author's personal clinical experience.
RESULTS: Hidradenitis suppurativa, also known as acne inversa, is a follicular occlusion disease that can severely reduce quality of life. Staphylococci and other pathogenic bacteria frequently colonize the lesions, but the disease is not primarily a bacterial infection. Smoking and obesity can worsen disease activity. Moderate and severe disease is usually treated with excisional surgery. Antibiotics, often tetracyclines, are indicated for mild disease and as an adjunct to surgery in more severe disease. Antibiotics, however, are not curative. New treatment options, such as TNF-alpha inhibitors and zinc gluconate should still be considered experimental.
INTERPRETATION: Hidradenitis suppurativa is probably underdiagnosed. The disease is often recalcitrant to treatment. The effect of medical treatment is not supported by high quality evidence.
Labels: acne inversa, antibiotics, boils, diagnose, follicular occlusion disease, Hidradenitis suppurativa, inflammatory skin disease, recurrent tender nodules
Routine packing of simple cutaneous abscesses is painful and probably unnecessary.
Department of Emergency Medicine, Albert Einstein Medical Center, Philadelphia, PA, USA. omalleyg@einstein.edu
OBJECTIVES: The objective was to determine whether the routine packing of simple cutaneous abscesses after incision and drainage (I&D) confers any benefit over I&D alone.
METHODS: In a prospective, randomized, single-blinded trial, subjects with simple cutaneous abscesses (less than 5 cm largest diameter) underwent incision, drainage, irrigation, and standard abscess preparation in the usual manner. Subjects were then randomized to either packing or no-packing. Visual analog scales (VAS; 100 mm) of pain were recorded in the emergency department (ED). All patients received trimethoprim-sulfamethoxazole (TMP-SMX), ibuprofen, and narcotic prescriptions, recorded twice daily VAS pain scores, and returned in 48 hours at which time dressings and packing, if present, were removed and a physician blinded to the randomization and not part of the initial visit repeated measurements and determined the need for further intervention.
RESULTS: Forty-eight subjects were included in the final analysis. There were no significant differences in age, sex, abscess location, or initial pain scores between the two groups. There was no significant difference in need for a second intervention at the 48-hour follow-up between the packed (4 of 23 subjects) and nonpacked (5 of 25 subjects) groups (p = 0.72; relative risk = 1.3, 95% confidence interval [CI] = 0.4 to 4.2). Patients in the group that received packing reported higher pain scores immediately postprocedure (mean difference = 23.8 mm; p = 0.014, 95% CI = 5 to 42 mm) and at 48 hours postprocedure (mean difference = 16.4 mm; p = 0.03, 95% CI = 1.6 to 31.2 mm), as well as greater use of ibuprofen (mean difference = 0.32; p = 0.12, 95% CI = -1.4 to 2.0) and oxycodone/acetaminophen (mean difference = 2.19; p = 0.03, 95% CI = 0.2 to 4.1).
CONCLUSION: In this pilot study, not packing simple cutaneous abscesses did not result in any increased morbidity, and patients reported less pain and used fewer pain medications than packed patients.
Labels: abscess, cutaneous abscess, management, packing, Trimethoprim-sulfamethoxazole, wound
Staphylococcal scalded skin syndrome in an adult patient with T-lymphoblastic non-Hodgkin's lymphoma.
Klinik fur Hamatologie/Onkologie, Universitatsklinikum Magdeburg, Magdeburg, Germany. katrin.scheinpflug@med.ovgu.de
BACKGROUND: Staphylococcal scalded skin syndrome (SSSS) is an exfoliative dermatitis caused by Staphylococcus aureus infection. In contrast to infants, it is rarely observed in adults. SSSS in adults usually occurs in predisposed individuals such as those with renal failure or immunodeficiency, but has also been reported in otherwise healthy subjects. The reported mortality rate in adults is usually high because of serious underlying disease.
PATIENT AND METHODS: We report a case of SSSS in a young female patient with T-lymphoblastic lymphoma, who survived this potentially lethal complication.
CONCLUSIONS: To the best of our knowledge, this is the first case of SSSS in an adult patient with T-lymphoblastic non-Hodgkin's lymphoma. Clinicians should be aware of SSSS as a rare but potentially fatal disorder, particularly in adult patients with malignancies undergoing aggressive chemotherapy.
Labels: Exfoliative dermatitis, Exfoliative toxins, Non-Hodgkin's lymphoma, Staphylococcal scalded skin syndrome
Cat scratch disease: a diagnostic conundrum
Cat scratch disease: a diagnostic conundrum
* Department of Sexual Health & HIV Medicine, St Stephens Centre, Chelsea & Westminster Hospital, 369 Fulham Road, London SW10 9NH; Department of Microbiology, Wexham Park Hospital, Slough; The Garden Clinic, Upton Hospital, Slough, UK
Correspondence to: Dr C Scott Email: christopher.scott@chelwest.nhs.uk
Key Words: cat scratch disease • Bartonella henselae • Lymphogranuloma venereum • inguinal lymphadenopathy
We report the case of a patient who presented to a clinic for evaluation of inguinal lymphadenopathy. Histology of the lymph nodes revealed micoabscess formation suggesting infection with Lymphogranuloma venereum (LGV) or Bartonella henselae – the causative agent in cat scratch disease (CSD). The patient recalled no preceding animal exposure. Clinical and serological findings initially suggested early LGV but convalescent serology supported CSD. This serves as an important reminder that B. henselae infection should be considered a cause of regionallymphadenopathy in individuals suspected of having LGV.
Labels: Bartonella henselae, cat scratch disease, inguinal lymphadenopathy, Lymphogranuloma venereum
Thursday, September 24, 2009
Guidelines Issued for Management of Opportunistic Infections Among HIV-Exposed Children
News Author: Laurie Barclay, MDCME Author: Charles P. Vega, MD, FAAFP
September 8, 2009 — Children who either have been exposed to HIV or who are infected with HIV are at increased risk for certain opportunistic diseases, according to new recommendations published online August 26 in the Morbidity and Mortality Weekly Report.
The new guidelines were issued jointly by the US Centers for Disease Control and Prevention, the National Institutes of Health (NIH), the HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics.
These guidelines update previous recommendations for clinicians and other healthcare practitioners providing medical care for HIV-exposed or HIV-infected children. Earlier guidelines were last published in 2002 and 2004, respectively.
"In the pre-antiretroviral era and before development of potent combination highly active antiretroviral treatment (HAART) regimens, opportunistic infections (OIs) were the primary cause of death in [HIV]-infected children," write Lynne M. Mofenson, MD, from the NIH in Bethesda, Maryland, and colleagues.
"Current HAART regimens suppress viral replication, provide significant immune reconstitution, and have resulted in a substantial and dramatic decrease in [AIDS]-related OIs and deaths in both adults and children.... Despite this progress, prevention and management of OIs remain critical components of care for HIV-infected children."
Development of Updated Guidelines
The Pediatric Opportunistic Infections Working Group, a panel of experts from the US government and academic institutions specializing in pediatric HIV infection and other infectious diseases, developed recommendations for the most effective strategies for diagnosis, prevention, and treatment of OIs.
For each OI, a pediatric specialist expert in that OI reviewed the literature for new information published since the previous guidelines were issued. In June 2007, revised recommendations were proposed at an NIH meeting, and the draft guidelines were revised further, reviewed and approved by the working group, and approved by the issuing organizations.
In addition to covering the management of opportunistic diseases encountered in the United States (Pneumocystis pneumonia, Toxoplasma gondii, Mycobacterium avium complex, Coccidioides species, Cryptococcus neoformans, Histoplasma capsulatum, microsporidiosis, cytomegalovirus, invasive bacterial infections, bartonellosis, Candida [esophageal], and herpes simplex virus), the guidelines also discuss malaria — an OI that could be acquired during international travel.
For each OI, the report summarizes epidemiology, clinical presentation, and diagnosis in children. Main topics include preventing exposure to OIs, using chemoprophylaxis and/or vaccination to prevent infection, discontinuing primary prophylaxis after immune reconstitution, treating OIs, monitoring for adverse effects during treatment, managing treatment failure, preventing recurrence of OIs, and discontinuing secondary prophylaxis after immune reconstitution.
A working group of experts specializing in adult HIV and infectious disease prepared a separate report on the prevention and treatment of OIs in HIV-infected adults and postpubertal adolescents, titled "Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents."
Populations Affected by OIs
Because HIV-infected women coinfected with opportunistic pathogens may be more likely than women uninfected with HIV to transmit these OIs to their infants, an infected mother is an important pathway for OI transmission, as well as for HIV infection, among children. Furthermore, mothers and other family members coinfected with HIV and certain opportunistic pathogens may be more likely to transmit these infections horizontally to young children, increasing the probability that the child will primarily acquire these infections.
OIs may therefore affect not just HIV-infected infants but also HIV-exposed but uninfected infants who become infected by the pathogen via HIV-infected mothers or family members with coinfections. For these reasons, the updated guidelines for treating OIs in children consider treatment of infections among all children — both HIV-infected and uninfected — born to HIV-infected women.
Incidence of HIV infection is rising both among adolescents with perinatal infection who have survived into their teenage years and among youth with behaviorally acquired HIV infection. The adult OI guidelines are applicable to postpubertal adolescents, but younger prepubertal or pubertal adolescents may have differing drug pharmacokinetics and response to treatment, with management best served by the pediatric guidelines.
Updated Recommendations
Since the previous versions of these guidelines, major changes in the new recommendations are as follows:
Increased emphasis on the importance of antiretroviral therapy to prevent and treat OIs, particularly those OIs for which no specific treatment is available.
New evidence regarding diagnosis and management of immune reconstitution inflammatory syndromes.
New information concerning management of antiretroviral therapy in children with OIs, including potential drug–drug interactions.
New strategies for diagnosis of HIV infection and for presumptively ruling out HIV infection in infants that affect the need to start prophylaxis for the prevention of Pneumocystis jirovecii pneumonia in neonates. Prophylaxis against Pneumocystis carinii should be considered in all infants exposed to HIV.
Updated recommendations for immunizing HIV-exposed and HIV-infected children against hepatitis A, human papillomavirus, meningococcus, and rotavirus. Children with HIV infection and good immune function should be routinely vaccinated against varicella, measles-mumps-rubella, and human papillomavirus. To weigh potential risks and benefits of vaccination against rotavirus in an infant exposed to HIV infection, expert consultation may be needed.
New sections on aspergillosis; bartonella; human herpes viruses 6, 7, and 8; malaria; and progressive multifocal leukodystrophy. Children infected with HIV do not require routine prophylaxis against aspergillosis, coccidiomycosis, or cryptococcal disease.
New guidelines for discontinuing OI prophylaxis after immune reconstitution in children.
In addition, there are 6 tables with information concerning prevention and treatment of OIs in children and 2 figures depicting immunization recommendations for children aged 0 to 6 years and 7 to 18 years. The guidelines authors acknowledge that treatment of OIs is an evolving science and that therapeutic options and preferences may change on the basis of the availability of new agents or clinical data on existing agents. The recommendations in these guidelines will therefore be updated periodically and posted on the NIH AIDSinfo Web site.
Morb Mortal Wkly Rep. Published online August 26, 2009.
Clinical Context
The main cause of HIV infection among children is vertical transmission from their mother, and the current guidelines highlight that the mother and nuclear family unit continue to be a strong potential reservoir for OIs as these children grow. These OIs may also infect infants without HIV infection. Therefore, the authors of the current guidelines focus their recommendations regarding OI prevention and treatment to all children born to women with HIV infection.
The guidelines regarding OIs among children were last updated in 2004. The current revised recommendations were initially proposed by an expert panel at a meeting of the NIH in 2007 and were then endorsed by multiple governmental and physician specialty groups.
Study Highlights
The use of HAART among children can be useful to both prevent and treat OIs for which specific treatments are less effective, including infections such as cryptosporidiosis and microsporidiosis.
Immune reconstitution inflammatory syndrome (IRIS) can occur in children after the initiation of treatment of HIV infection. However, among adults, up to 30% of cases of IRIS may be present at 3 months after initiation of HAART. HAART should be continued in cases of IRIS, and nonsteroidal anti-inflammatory drugs should be added, along with close supervision, for adequate treatment of most moderate cases. Antibiotics are unnecessary in the treatment of IRIS.
The best timing to initiate HAART after an OI remains unclear and needs to be individualized to the patient's needs.
Vaccination against varicella and measles-mumps-rubella may be considered among HIV-infected children with age-specific CD4 levels of at least 15%.
Although vaccine immune response may be less than among immunocompetent peers, the human papillomavirus vaccine may be administered to girls with HIV infection.
There are no safety data regarding the application of the rotavirus vaccine to infants who are potentially immunocompromised, and the diagnosis of HIV infection in the infant may not even be established at the time of the first vaccination. Whether to provide vaccination against rotavirus among infants exposed to HIV may require consultation with an expert in infectious disease or immunology.
Bartenellosis may be prevented by the avoidance of body lice, cats, and cat fleas. Moderate cat-scratch disease among children with HIV infection typically does not respond to antibiotic therapy, and treatment is supportive.
Previous estimates have found that 1.1% of children with tuberculosis have a coinfection with HIV, a lower rate vs the adult population. Children with HIV infection should receive annual tuberculin skin tests. Treatment of active tuberculosis is similar among children with and without HIV, although the concurrent use of HAART can complicate tuberculosis treatment (particularly the use of rifamycins). The usual treatment period is 6 months.
Clarithromycin and azithromycin may be used to prevent M avium complex disease in children, but children with a sustained positive immune response to HAART for 3 months or longer may discontinue antibiotic prophylaxis against M avium complex.
Prophylaxis against aspergillosis and coccidiomycosis among children with HIV infection is not recommended. Voriconazole is the first-line therapy for active aspergillosis, and disseminated coccidiomycosis infection requires treatment with amphotericin B.
Children with HIV infection do not require routine testing for the cryptococcal antigen or prophylaxis against infection with cryptococcus.
Conversely, infants born to mothers with HIV infection should be considered for antibiotic prophylaxis against P carinii beginning at ages 4 to 6 weeks. Trimethoprim-sulfamethoxazole is the first-line agent for prophylaxis.
Children with HIV infection traveling to endemic areas of malaria infection should receive prophylactic antibiotics against malaria, and care must be taken to avoid significant interactions with HAART, if possible. Trimethoprim-sulfamethoxazole should not be used as prophylaxis against malaria.
Clinical Implications
The current study recommends routine vaccination against varicella, measles-mumps-rubella, and human papillomavirus among children with HIV infection and good immune function. However, vaccination against rotavirus may require consultation with an expert to weigh potential risks and benefits in an infant exposed to HIV infection.
Children with HIV infection do not require routine prophylaxis against aspergillosis, coccidiomycosis, or cryptococcus, but all infants exposed to HIV should be considered for prophylaxis against P carinii.
Medscape
Labels: children, guidlines, HAART, HIV, human papillomavirus, Immune reconstitution inflammatory syndrome, Infection, measles, meningococcus, mumps, rotavirus, rubella, trteatment, varicella
Sunday, September 20, 2009
Complications of Infective Endocarditis.
Cardiovasc Hematol Disord Drug Targets. 2009 Sep
Mocchegiani R, Nataloni M.
Via Tommasi 5, 60124 Ancona, Italy. r_mocc@yahoo.it.
Infective endocarditis (IE) is a lethal disease if not promptly treated with antibiotics, either in association with surgery or not. The incidence of disease has not decreased over the last decades due to the change of risk conditions. Complications of IE may involve cardiac structures when the infection spreads within the heart, or extra cardiac ones when the cause is usually from embolic origin; they may also be due to medical treatment or to the septic condition itself. A variety of complications may occur in most of patients. The literature reports one complication of IE in 57%, two in 26% and three or more in about 14% of patients examined. The frequency of specific complications depends on variables as the infecting pathogen, duration of disease before therapy and type of treatment. However it is often difficult to assess the true incidence of complications because the published reviews in literature are frequently based on retrospective chart reviews and different diagnostic criteria are used. The decision over either indication or timing of surgery should be individualized and based on a multidisciplinary approach involving at least cardiologists and cardiac surgeons. Congestive heart failure (CHF) is the most important complication of IE, which has the greatest impact on prognosis. Periannular abscesses are a relatively common complication of IE (42% to 85% of cases during surgery or at autopsy respectively), associated with a higher morbidity and mortality. Systemic embolization occurs in 22% to 50% of cases; emboli may involve major arteries, mostly affecting the central nervous system, but also other organs. Splenic abscess is a rare complication of IE, due to direct seeding of spleen by an embolus or bacterial seeding of a bland infarction. Neurological complications develop in 20% to 40% of patients with IE and represent a dangerous subset of complications. Mycotic aneurysms are rare, resulting from diffusion of infection to the vessel wall. Actually the clinical profile, the best treatment (medical or surgical approach) and outcome of complicated IE are not well defined. Changing trends in aetiology of IE with emerging infections from Staphylococci, bacteria of the HACEK group and Fungi have resulted in an increased frequency of culture negative IE. Sepsis or persistent fever despite appropriate antimicrobial therapy, recurrent emboli, heart failure or new pathologic murmurs suggest haemodynamic impairment and/or infection extending beyond the valve leaflet or prosthetic valvular annulus. The course of the disease will consequently get worse with an increasing need of surgery. Patients who develop abscesses are more likely to undergo surgery than those who do not (84-91% vs 36%), and also their in-hospital mortality rate is higher (19% vs 11%). A prompt detection of complications often allows an earlier surgical treatment which represents the best way to improve the outcome. The introduction of molecular methods techniques has increased the ability to identify the causal agents of IE, mostly in cases of culture negative endocarditis. Echocardiography, mainly from transesophageal (TEE) approach, has significantly improved the evaluation of IE allowing to detect the specific signs of the disease as vegetations, abscesses, valve insufficiency, prosthetic valve dehiscence, fistulas. In our 3rd referral Hospital (Lancisi Heart Hospital, Ancona, Italy) we performed a follow-up (mean 8.26 years) of 15 patients with periannular complications associated with IE. The long term follow-up showed low mortality rate, high incidence of reintervention, improved New York Heart Association (NYHA) class in survivors and no changes of the lesions at the echocardiographic examination, suggesting that periannular complications have not significantly influenced the overall survival in our patients at the follow-up.
PMID: 19751182 [PubMed - as supplied by publisher]
Labels: antibiotics, Complications; Infections, course of disease, Echocardiography, Infective Endocarditis, Mycotic aneurysms, Periannular abscesses, spenic abscess, valve insufficiency
Thursday, September 17, 2009
Corruption of Innate Immunity by Bacterial Proteases.
J Innate Immun. 2009 Jan
Potempa J, Pike RN.
Department of Microbiology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland, and Department of Biochemistry and Molecular Biology, University of Georgia, Athens, GA, USA.
The innate immune system of the human body has developed numerous mechanisms to control endogenous and exogenous bacteria and thus prevent infections by these microorganisms. These mechanisms range from physical barriers such as the skin or mucosal epithelium to a sophisticated array of molecules and cells that function to suppress or prevent bacterial infection. Many bacteria express a variety of proteases, ranging from non-specific and powerful enzymes that degrade many proteins involved in innate immunity to proteases that are extremely precise and specific in their mode of action. Here we have assembled a comprehensive picture of how bacterial proteases affect the host's innate immune system to gain advantage and cause infection. This picture is far from being complete since the numbers of mechanisms utilized are as astonishing as they are diverse, ranging from degradation of molecules vital to innate immune mechanisms to subversion of the mechanisms to allow the bacterium to hide from the system or take advantage of it. It is vital that such mechanisms are elucidated to allow strategies to be developed to aid the innate immune system in controlling bacterial infections.
PubMedLabels: bacterial infections, Bacterial Proteases, endogenous bacteria, enzymes, exogenous bacteria, innate immunity
