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Bringing impetigo treatment into the 21st century
P1601
P1603
Syphilis: Experience of an AIDS referral center in Mexico City Carla Archer-Dubon, Instituto Nacional de Ciencias Me´dicas y Nutricio´ n Salvador Zubira´n, Mexico; Elva Ca´rdenas-Zeivy, MD, Instituto Nacional de Ciencias Me´dicas y Nutricio´n Salvador Zubira´n, Mexico; Rocı´o Orozco-Topete, Instituto ´ n Salvador Zubira´n, Mexico Nacional de Ciencias Me´dicas y Nutricio
Bringing impetigo treatment into the 21st century Lawrence Parish, MD, Jefferson Medical College, Philadelphia, PA, United States; Jennifer Parish, MD, Jefferson Medical College, Philadelphia, PA, United States; Daniel Parish, MD, JD, Pennsylvania Hospital, Philadelphia, PA, United States The treatment of impetigo has always been challenging, and a review of the literature over the last 200 years indicates the lack of success with a wide variety of treatment options. In the 1800s, potassium arsenite (Fowler’s solution), arsenic and mercuric iodide (Donovan’s solution), silver nitrate and hydrocyanic acid, and a compound of sarsaparilla and sassafras root (sarsae) were used with limited success. The identity of the causative pathogens was being debated, and it was only at the end of that century that the fungal theory was discredited. The beginning of the 20th century saw the unguents of ammonia or boric acid used on troops in the trenches during World War I, but again results were disappointing and tincture of iodine paint or methylated spirit applied after removal of crusts were considered more effective in difficult conditions. Ten years later, the ‘‘in vogue’’ treatment for children with impetigo was to produce painful third-degree erythema with ultraviolet light for 12 to 14 days after removal of crusts. By the middle of the century, it was still unknown if impetigo was contagious, and there were claims that it was easy to treat if three rules were followed: never scratch, never remove scabs, and never let water touch the skin. Around this time, the antibiotic era arrived with the sulfonamide drugs, and treatment for 9 days with sulfathiazole was reported as uniformly successful. Penicillins and cephalosporins took over in the second half of the century and topical agents were developed that appeared to be as effective as oral antibiotics, at least for localized impetigo. As their use increased, so did antibiotic resistance, and there were calls to limit the use of these agents to maintain their efficacy. Since mupirocin became available in the United States some 20 years ago, there have been no advances in topical antibacterial treatments for impetigo until recently. Retapamulin is a semisynthetic member of the pleuromutilin class of antibiotics with a new mode of action and excellent activity against S aureus and S pyogenes. Retapamulin has no target-specific cross-resistance with other antibiotics and limited potential for resistance development. The convenient dosing (BID for 5 days) fits well with 21st-century living and provides good efficacy and tolerability.
Background: Syphilis rates are rising worldwide, especially in HIV/AIDS population. This has public health implications, because the risk behaviors for syphilis and HIV are similar and syphilis lesions increase the risk of HIV transmission. An extensive literature search revealed scarce information regarding the Mexican experience and since our institution is a tertiary care facility and a national AIDS referral center, we sought to estimate the prevalence of syphilis and describe clinical-serological characteristics in our population. Methods: The electronic database of all patients seen at the institution between 1987 and 2007 was retrospectively reviewed and all medical records with the diagnosis of ‘‘syphilis’’ were extracted. Pathology records (1982-to date) of the Dermatology Department were also reviewed. Medical records were reviewed for age, sex, presenting symptoms, stage of syphilis, VDRL, FTA-ABS, HIV status, CD4 count, viral load, and date of syphilis diagnosis. Results: Twenty-two medical records were identified, of which 18 had HIV/AIDS. Three patients were otherwise healthy and one had liver cirrhosis. Twenty-one patients were male, one female, with a mean age of 41.1 years. No patients with primary syphilis were seen, 11 presented mucocutaneous lesions of secondary syphilis, 1 had syphilitic uveitis, 1 had neurosyphilis and 8 had latent syphilis. All except one were VDRL (1) and 16 had (1) FTA-ABS. Stages of the HIV/AIDS patients at moment of syphilis diagnosis were as follows: 10 in stage C3; 2 in B3; 2 in B2; 1 in A1; 1 in A2; 1 in A3; and 1 in C2; mean CD4 count was 153 and mean viral load was 75,000. All except one presented lesions after 2002. Conclusions: Although rates in Mexico have increased in the past few years, less than 2% of our AIDS population have sought medical attention for syphilis, which is surprisingly low. We believe this does not accurately reflect the worldwide rising trend of syphilis, and it is probably being severely underdiagnosed in our country. Contrary to recent reports we did not find seronegative secondary syphilis. All health personnel involved in the care of HIV/AIDS patients need to be aware of the cutaneous lesions of syphilis in order to establish a prompt diagnosis and avoid lifethreatening sequelae in these subjects.
90% supported by GSK.
Commercial support: None identified.
P1602
P1604
University of Miami/Jackson Memorial Hospital Hansen’s disease program establishing appropriate management of misdiagnosed leprosy Ivan Camacho, MD, University of Miami, Miami, FL, United States; Anne Burdick, MD, MPH, University of Miami, Miami, FL, United States
Ecthyma gangrenosum following pneumonia Sian Hickey, MBChB, Broadgreen Hospital, Liverpool, Merseyside, United Kingdom; Richard Azurdia, MBBCh, Broadgreen Hospital, Liverpool, Merseyside, United Kingdom
Global travel and recent immigration patterns are bringing leprosy to nonendemic areas where physicians are unfamiliar with the various presentations of this disease. Leprosy manifestations depend on the individual’s cell-mediated immunity to Mycobacterium leprae. Diagnosis is often delayed, resulting in neurologic complications and deformities. The University of Miami/Jackson Memorial Hospital Hansen’s Disease Program diagnosed 12 new patients in 2006 and provided multidrug therapy (MDT): rifampin, dapsone, and clofazimine. Two patients whose leprosy was misdiagnosed for many years are presented. Case 1: a 43-year-old Indian male presented with a 2-year history of pain and swelling in both hands and feet. He was diagnosed with rheumatoid arthritis by a rheumatologist and treated with methotrexate and prednisone with mild improvement. A year later, he developed numbness, worsening edema, and an asymptomatic rash of his hands and feet, prompting resumption of prednisone. On exam, erythematous plaques were present on dorsal right hand, right elbow, and left foot. Skin biopsy revealed granulomatous infiltrates in a neurovascular distribution with rare acid-fast bacilli, consistent with tuberculoid leprosy. MDT was started with improvement of skin lesions. Prednisone was continued for his type 1 reversal reaction with decreased hand and foot edema and pain. Case 2: a 31-year-old Colombian female presented with a 15-year history of nasal congestion, rhinorrhea, and intermittent epistaxis. She failed medical management for presumed chronic rhinitis and underwent septoplasty that that revealed extensive nasal cartilage and bone destruction. Nasal mucosa histology showed granulomatous inflammation with massive infiltration of acid-fast bacilli in histiocytes and nerves. On exam, midfacial edema and scattered indurated pink papules on the right thigh and left foot were noted. A history of lower extremity numbness was obtained. Skin biopsy revealed similar pathology and slit smears showed a bacillary index range of 3 to 5 (on a semi-logarithmic scale of 06). MDT was started with resolution of nasal symptoms and skin lesions after 4 months. Awareness of the diverse presentations of leprosy will promote early diagnosis and treatment to avoid significant nerve damage and disability.
Ecthyma gangrenosum (EG) is a cutaneous infection usually caused by Pseudomonas aeruginosa in the setting of an immunocompromised patient. The skin lesions start as painless erythematous macules, which rapidly blister and develop a central haemorrhagic ulcer which then forms a thick grey/black eschar. Prompt recognition of the condition is important as early antibiotic therapy significantly reduces mortality. We report a case of EG following severe pneumonia. Our patient is a 52-year-old female with cerebral palsy who lives in a nursing home where she receives 24-hour care. She presented to our department with a 2-week history of two skin lesions, on the right upper back and over the right greater trochanter. These started as painless areas of erythema which then ulcerated and were accompanied by lethargy, fatigue, and loss of appetite. Four weeks before the development of the lesions, our patient had been discharged from the hospital following treatment for severe left lower lobe pneumonia. Clinically both lesions measured approximately 6 cm in diameter, had a thick central black eschar, and a surrounding collar of fixed indurated erythema. Our patient was shivering and tachycardic. Subsequent investigations confirmed pseudomonas on skin swab but blood cultures were negative. Skin biopsy showed punched out ulcers with inflammatory slough and some fat necrosis. Treatment with intravenous Piperacillin resulted in a marked improvement in our patients’ condition. Topical hydrogel preparations, surgical debridement, and larval therapy promoted healing of the cutaneous ulcers. We feel our patient is interesting as she had no definite reason to be immunosupressed as a cause of her EG, but acknowledge that her preceeding severe illness may have compromised her immune function. Partial antibiotic therapy before blood culture sampling may explain the negative findings, but the literature reports both bacteraemic and non-bacteraemic forms of EG. Cases of EG are also reported in healthy children following antibiotic therapy for nonpseudomonal infection, and also following prolonged antibiotic therapy in adults. Both these factors may be relevant in our case because of the preceding treatment for her pneumonia.
Commercial support: None identified.
Commercial support: None identified.
FEBRUARY 2008
J AM ACAD DERMATOL
AB87
P1603
Syphilis: Experience of an AIDS referral center in Mexico City Carla Archer-Dubon, Instituto Nacional de Ciencias Me´dicas y Nutricio´ n Salvador Zubira´n, Mexico; Elva Ca´rdenas-Zeivy, MD, Instituto Nacional de Ciencias Me´dicas y Nutricio´n Salvador Zubira´n, Mexico; Rocı´o Orozco-Topete, Instituto ´ n Salvador Zubira´n, Mexico Nacional de Ciencias Me´dicas y Nutricio
Bringing impetigo treatment into the 21st century Lawrence Parish, MD, Jefferson Medical College, Philadelphia, PA, United States; Jennifer Parish, MD, Jefferson Medical College, Philadelphia, PA, United States; Daniel Parish, MD, JD, Pennsylvania Hospital, Philadelphia, PA, United States The treatment of impetigo has always been challenging, and a review of the literature over the last 200 years indicates the lack of success with a wide variety of treatment options. In the 1800s, potassium arsenite (Fowler’s solution), arsenic and mercuric iodide (Donovan’s solution), silver nitrate and hydrocyanic acid, and a compound of sarsaparilla and sassafras root (sarsae) were used with limited success. The identity of the causative pathogens was being debated, and it was only at the end of that century that the fungal theory was discredited. The beginning of the 20th century saw the unguents of ammonia or boric acid used on troops in the trenches during World War I, but again results were disappointing and tincture of iodine paint or methylated spirit applied after removal of crusts were considered more effective in difficult conditions. Ten years later, the ‘‘in vogue’’ treatment for children with impetigo was to produce painful third-degree erythema with ultraviolet light for 12 to 14 days after removal of crusts. By the middle of the century, it was still unknown if impetigo was contagious, and there were claims that it was easy to treat if three rules were followed: never scratch, never remove scabs, and never let water touch the skin. Around this time, the antibiotic era arrived with the sulfonamide drugs, and treatment for 9 days with sulfathiazole was reported as uniformly successful. Penicillins and cephalosporins took over in the second half of the century and topical agents were developed that appeared to be as effective as oral antibiotics, at least for localized impetigo. As their use increased, so did antibiotic resistance, and there were calls to limit the use of these agents to maintain their efficacy. Since mupirocin became available in the United States some 20 years ago, there have been no advances in topical antibacterial treatments for impetigo until recently. Retapamulin is a semisynthetic member of the pleuromutilin class of antibiotics with a new mode of action and excellent activity against S aureus and S pyogenes. Retapamulin has no target-specific cross-resistance with other antibiotics and limited potential for resistance development. The convenient dosing (BID for 5 days) fits well with 21st-century living and provides good efficacy and tolerability.
Background: Syphilis rates are rising worldwide, especially in HIV/AIDS population. This has public health implications, because the risk behaviors for syphilis and HIV are similar and syphilis lesions increase the risk of HIV transmission. An extensive literature search revealed scarce information regarding the Mexican experience and since our institution is a tertiary care facility and a national AIDS referral center, we sought to estimate the prevalence of syphilis and describe clinical-serological characteristics in our population. Methods: The electronic database of all patients seen at the institution between 1987 and 2007 was retrospectively reviewed and all medical records with the diagnosis of ‘‘syphilis’’ were extracted. Pathology records (1982-to date) of the Dermatology Department were also reviewed. Medical records were reviewed for age, sex, presenting symptoms, stage of syphilis, VDRL, FTA-ABS, HIV status, CD4 count, viral load, and date of syphilis diagnosis. Results: Twenty-two medical records were identified, of which 18 had HIV/AIDS. Three patients were otherwise healthy and one had liver cirrhosis. Twenty-one patients were male, one female, with a mean age of 41.1 years. No patients with primary syphilis were seen, 11 presented mucocutaneous lesions of secondary syphilis, 1 had syphilitic uveitis, 1 had neurosyphilis and 8 had latent syphilis. All except one were VDRL (1) and 16 had (1) FTA-ABS. Stages of the HIV/AIDS patients at moment of syphilis diagnosis were as follows: 10 in stage C3; 2 in B3; 2 in B2; 1 in A1; 1 in A2; 1 in A3; and 1 in C2; mean CD4 count was 153 and mean viral load was 75,000. All except one presented lesions after 2002. Conclusions: Although rates in Mexico have increased in the past few years, less than 2% of our AIDS population have sought medical attention for syphilis, which is surprisingly low. We believe this does not accurately reflect the worldwide rising trend of syphilis, and it is probably being severely underdiagnosed in our country. Contrary to recent reports we did not find seronegative secondary syphilis. All health personnel involved in the care of HIV/AIDS patients need to be aware of the cutaneous lesions of syphilis in order to establish a prompt diagnosis and avoid lifethreatening sequelae in these subjects.
90% supported by GSK.
Commercial support: None identified.
P1602
P1604
University of Miami/Jackson Memorial Hospital Hansen’s disease program establishing appropriate management of misdiagnosed leprosy Ivan Camacho, MD, University of Miami, Miami, FL, United States; Anne Burdick, MD, MPH, University of Miami, Miami, FL, United States
Ecthyma gangrenosum following pneumonia Sian Hickey, MBChB, Broadgreen Hospital, Liverpool, Merseyside, United Kingdom; Richard Azurdia, MBBCh, Broadgreen Hospital, Liverpool, Merseyside, United Kingdom
Global travel and recent immigration patterns are bringing leprosy to nonendemic areas where physicians are unfamiliar with the various presentations of this disease. Leprosy manifestations depend on the individual’s cell-mediated immunity to Mycobacterium leprae. Diagnosis is often delayed, resulting in neurologic complications and deformities. The University of Miami/Jackson Memorial Hospital Hansen’s Disease Program diagnosed 12 new patients in 2006 and provided multidrug therapy (MDT): rifampin, dapsone, and clofazimine. Two patients whose leprosy was misdiagnosed for many years are presented. Case 1: a 43-year-old Indian male presented with a 2-year history of pain and swelling in both hands and feet. He was diagnosed with rheumatoid arthritis by a rheumatologist and treated with methotrexate and prednisone with mild improvement. A year later, he developed numbness, worsening edema, and an asymptomatic rash of his hands and feet, prompting resumption of prednisone. On exam, erythematous plaques were present on dorsal right hand, right elbow, and left foot. Skin biopsy revealed granulomatous infiltrates in a neurovascular distribution with rare acid-fast bacilli, consistent with tuberculoid leprosy. MDT was started with improvement of skin lesions. Prednisone was continued for his type 1 reversal reaction with decreased hand and foot edema and pain. Case 2: a 31-year-old Colombian female presented with a 15-year history of nasal congestion, rhinorrhea, and intermittent epistaxis. She failed medical management for presumed chronic rhinitis and underwent septoplasty that that revealed extensive nasal cartilage and bone destruction. Nasal mucosa histology showed granulomatous inflammation with massive infiltration of acid-fast bacilli in histiocytes and nerves. On exam, midfacial edema and scattered indurated pink papules on the right thigh and left foot were noted. A history of lower extremity numbness was obtained. Skin biopsy revealed similar pathology and slit smears showed a bacillary index range of 3 to 5 (on a semi-logarithmic scale of 06). MDT was started with resolution of nasal symptoms and skin lesions after 4 months. Awareness of the diverse presentations of leprosy will promote early diagnosis and treatment to avoid significant nerve damage and disability.
Ecthyma gangrenosum (EG) is a cutaneous infection usually caused by Pseudomonas aeruginosa in the setting of an immunocompromised patient. The skin lesions start as painless erythematous macules, which rapidly blister and develop a central haemorrhagic ulcer which then forms a thick grey/black eschar. Prompt recognition of the condition is important as early antibiotic therapy significantly reduces mortality. We report a case of EG following severe pneumonia. Our patient is a 52-year-old female with cerebral palsy who lives in a nursing home where she receives 24-hour care. She presented to our department with a 2-week history of two skin lesions, on the right upper back and over the right greater trochanter. These started as painless areas of erythema which then ulcerated and were accompanied by lethargy, fatigue, and loss of appetite. Four weeks before the development of the lesions, our patient had been discharged from the hospital following treatment for severe left lower lobe pneumonia. Clinically both lesions measured approximately 6 cm in diameter, had a thick central black eschar, and a surrounding collar of fixed indurated erythema. Our patient was shivering and tachycardic. Subsequent investigations confirmed pseudomonas on skin swab but blood cultures were negative. Skin biopsy showed punched out ulcers with inflammatory slough and some fat necrosis. Treatment with intravenous Piperacillin resulted in a marked improvement in our patients’ condition. Topical hydrogel preparations, surgical debridement, and larval therapy promoted healing of the cutaneous ulcers. We feel our patient is interesting as she had no definite reason to be immunosupressed as a cause of her EG, but acknowledge that her preceeding severe illness may have compromised her immune function. Partial antibiotic therapy before blood culture sampling may explain the negative findings, but the literature reports both bacteraemic and non-bacteraemic forms of EG. Cases of EG are also reported in healthy children following antibiotic therapy for nonpseudomonal infection, and also following prolonged antibiotic therapy in adults. Both these factors may be relevant in our case because of the preceding treatment for her pneumonia.
Commercial support: None identified.
Commercial support: None identified.
FEBRUARY 2008
J AM ACAD DERMATOL
AB87