Cutaneous leishmaniasis by a needlestick injury, an occupational infection?

Leishmaniasis is a parasitic disease caused by over 20 species of Leishmania. Transmission is mainly via sandfly bites infected with promastigotes, through the placenta from mother to child, by sexual intercourse, blood transfusion, and occupationally acquired by direct inoculation into the skin. Clinical manifestations vary from self-limited cutaneous disease to a life-threatening visceral infection. In November 2021, a 29-year-old otherwise healthy dermatology resident suffered an accidental needlestick injury while performing a biopsy on a patient with a presumptive diagnosis of an infectious dermatosis, later confirmed as mucocutaneous leishmaniasis caused by Leishmania panamensis. Later, the resident developed an erythematous, painless papule at the point of inoculation, with a central ulcer and painful enlargement of ipsilateral lymph nodes. Biopsy was compatible with leishmaniasis. After completing a 20-day treatment with meglumine antimoniate, the ulcer had healed completely. At the 6-month follow-up, both patients remain asymptomatic. This case serves as a reminder that health providers should have the proper training and knowledge of their hospital management protocol for occupational injuries. Moreover, physicians should bear in mind that leishmaniasis is not exclusively transmitted by sandfly vectors.

Intranasal Ketorolac for Acute Pain in Adult Emergency Department Patients.

Pain is a common complaint in the emergency department. An alternative to opioids is desirable. Oral medications are not feasible with gastrointestinal disorders or NPO. Intravenous medications require skill and time. Intravenous/intramuscular medications are painful with potential needlestick injury. Intranasal medications have rapid onset, easy administration, do not need skilled providers, and no risk of needlestick injury. A total of 28 adults with acute pain (numeric rating scale ≥ 4) received intranasal ketorolac. Numeric rating scale decreased in all: 32% complete pain relief, median (interquartile range) decrease -5 (-6.8 to -4) (p < .001). Pain relief onset was median [interquartile range] 5 (2.3, 15.0) min. Vital signs remained normal. There were no nasal mucosal changes, no complications. Minor side effects, mostly nasal burning, in 43%, resolved within 5 min. Patients and nurses were satisfied with intranasal ketorolac, and would use it again. Intranasal ketorolac had a rapid onset, was effective, safe, well tolerated with minor side effects that resolved quickly.

Change in hepatitis C virus positivity among needle-stick injury source patients: a 10-year experience in a Japanese tertiary hospital.

BACKGROUND: As a blood-borne pathogen, hepatitis C virus (HCV) has long been a major threat associated with needle-stick injuries (NSIs) mainly because no vaccine is available for HCV. Following an NSI, we usually test the source patient for HCV antibody (HCV-Ab). Since HCV-Ab positivity does not necessarily indicate current infection, HCV RNA is further examined in patients positive for HCV-Ab. Direct-acting antivirals (DAAs) have enabled us to treat most HCV-infected patients; therefore, we speculate that the rate of HCV RNA positivity among HCV-Ab-positive patients decreased after the emergence of DAAs. This cross-sectional study was performed to investigate the change in the actual HCV RNA positivity rate in source patients before and after the interferon (IFN)-free DAA era. METHODS: This was a cross-sectional study of NSI source patients at a tertiary academic hospital in Japan from 2009 to 2019. IFN-free DAA regimens were first introduced in Japan in 2014. Accordingly, we compared HCV status of NSI source patients that occurred between 2009 and 2014 (the era before IFN-free DAAs) with those that occurred between 2015 and 2019 (the era of IFN-free DAAs) in a tertiary care hospital in Japan. RESULTS: In total, 1435 NSIs occurred, and 150 HCV-Ab-positive patients were analyzed. The proportion of HCV RNA-positive patients significantly changed from 2009 through 2019 (p = 0.005, Cochran-Armitage test). Between 2009 and 2014, 102 source patients were HCV-Ab-positive, 78 of whom were also positive for HCV RNA (76.5%; 95%CI, 67.4-83.6%). Between 2015 and 2019, 48 patients were HCV-Ab-positive, 23 of whom were also positive for HCV RNA (47.9%; 95%CI, 34.5-61.7%; p = 0.0007 compared with 2009-2014). In the era of IFN-free DAAs, 9 of 23 HCV RNA-negative patients (39.1%) and 2 of 22 HCV RNA-positive patients (9.1%) were treated with an IFN-free combination of DAAs (p = 0.0351). Regarding the departments where NSIs occurred, HCV RNA-negative patients were predominant in departments not related to liver diseases in the era of IFN-free DAAs (p = 0.0078, compared with 2009-2014). CONCLUSIONS: Actual HCV RNA positivity in source patients of NSIs decreased after the emergence of IFN-free DAAs. IFN-free DAAs might have contributed to this reduction, and HCV RNA-negative patients were predominant in departments not related to liver diseases in the era of IFN-free DAAs.

Reversal of Digital Ischemia with Phentolamine After Accidental Epinephrine Injection.

BACKGROUND Accidental finger-stick injuries have been reported with epinephrine autoinjectors, such as EpiPen and EpiPen Jr, and can result in necrosis and digital ischemia. However, long-term adverse effects are very rare. The treatment for accidental finger-stick injuries is controversial and includes intra-arterial injections of vasodilating agents, topical vasodilators, and supportive management as needed. CASE REPORT Here, we report a case of a 26-year-old pharmacist who injected herself accidentally with an EpiPen on the tip of her index finger. Warm water and nitroglycerine gel did not alleviate her symptoms. After three hours, phentolamine was injected around the necrotic area, and the skin normalized. CONCLUSIONS All health professionals should be trained in how to handle epinephrine autoinjectors safely. Phentolamine may be efficacious in treating accidental finger-stick injuries from epinephrine autoinjectors.

Clinical Outcomes of Post-exposure Prophylaxis following Occupational Exposure to Human Immunodeficiency Virus at Dental Departments of Hiroshima University Hospital.

BACKGROUND: Dental professionals have so many opportunities to use injection needles and sharp instruments during dental treatment that they face an increased risk of needlestick injuries. This retrospective study reports the utilization and clinical outcomes of occupational post-exposure prophylaxis (PEP) with anti-retroviral agents after being potentially exposed to HIV at the dental departments of Hiroshima University Hospital. OBJECTIVE: This study reports the utilization and clinical outcomes of occupational post-exposure prophylaxis (PEP) with antiretroviral agents after being potentially exposed to HIV at dental departments of Hiroshima University Hospital. METHODS: Data on the clinical status of HIV-infected source patients and information on HIV-exposed dental professionals from 2007 to 2018 were collected. RESULTS: Five dentists with an average experience of 5.6 years (1-15 years) were exposed. The averaged CD4-positive cell number and HIV-RNA load were 1176 (768-1898) /µl and less than 20 copies/ml, respectively, in all the patients. Two of the five HIV exposed dentists received PEP. Three months after the exposures, all of their results were negative in HIV antibody/antigen tests. CONCLUSION: ; These data might support the concept of "undetectable equals untransmittable", although HIV exposure in this study was not through sexual transmission.

Flexor Compartment Infection Secondary to Bovine Injection Needlestick Injury: A Case Report.

CASE: Animal injection-related needlestick injuries are a common occupational hazard for livestock workers and veterinarians. Although often unreported, these injuries can cause significant damage and may require extensive medical and surgical management. This case describes a 69-year-old farmer who accidentally injected his forearm while vaccinating cattle, resulting in a flexor compartment infection. Conservative management with oral and intravenous antibiotics was unsuccessful, and he required multiple surgical debridements for definitive treatment CONCLUSIONS:: Animal injection-related needlestick injuries can present unique challenges to orthopaedic surgeons. Important considerations include the injury location, needle type, vaccine volume and components, injection pressure, and environmental contaminants.

Development of an HIV Postexposure Prophylaxis (PEP) Protocol for Trainees Engaging in Academic Global Health Experiences.

PROBLEM: Global health (GH) education programs have become increasingly common in U.S. medical schools and graduate medical education programs, with growing numbers of medical students, residents, and fellows participating in clinical experiences in settings with high HIV prevalence and limited resources. However, there are no guidelines for provision of HIV postexposure prophylaxis (PEP) to trainees engaging in these academic GH experiences. APPROACH: Faculty of the Global Health Education Programs (GHEP) at the David Geffen School of Medicine at UCLA and GH partner institutions recognized the need for PEP access for trainees engaged in GH experiences. In 2013-2014, key UCLA faculty collaborated in the development of the UCLA GHEP PEP Protocol, which includes provision of PEP medications to trainees prior to departure, an on-call infectious disease/HIV specialist to advise trainees who have exposures, and a system for following up with exposed trainees while on the GH rotation and after their return. OUTCOMES: Between February 2014 and September 2016, 112 medical students and 110 residents received education on the PEP protocol during their predeparture orientation. The protocol was used for 28 exposures (27 occupational, 1 nonoccupational), with PEP recommended in 3 occupational cases (all needlesticks) and the single nonoccupational case. There were no reported HIV seroconversions. NEXT STEPS: The authors plan to formally evaluate the PEP protocol, conduct a qualitative assessment with trainees and both UCLA and GH partner faculty, and discuss best practices with institutions across the United States and with GH partners.

Pseudomonas aeruginosa endophthalmitis caused by accidental iatrogenic ocular injury with a hypodermic needle.

Iatrogenic traumatic endophthalmitis is a rare but serious ocular infection that can lead to severe vision loss. A 44-year-old man presented with pain and decreased vision in the right eye 4 hours after injury with a hypodermic needle during irrigation of his eye. Slit-lamp examination revealed a penetrating corneal puncture and iris hole in the right eye. Twenty hours later, his visual acuity had decreased to hand motion, and severe fibrinoid uveitis was noted. He immediately underwent irrigation of the anterior chamber and intravitreal antibiotic injection. The right eye became painful again, and emergent vitrectomy combined with lensectomy was performed along with intravitreal antibiotic administration. The patient remained stable during the 2-month follow-up. Standard practice should be adopted when irrigating the eye to prevent this type of injury, and emergent surgical intervention is very important to preserve visual function.

[Early diagnosis of hepatitis C transmission after needlestick injury]. / Frühzeitige Diagnose einer Hepatitis-C-Übertragung nach Nadelstichverletzung.

Occupational transmission of hepatitis C (HCV) is rare but has been repeatedly described in the published literature. Early diagnosis and therapy of acute hepatitis C is associated with an excellent chance of permanent HCV elimination. The majority of chronic HCV infections, however, lead to a slowly progressive hepatitis with associated morbidity and risk of liver cirrhosis. For this reason the need for antiviral therapy has to be evaluated immediately.

Six years of epinephrine digital injections: absence of significant local or systemic effects.

STUDY OBJECTIVE: Epinephrine autoinjectors are known to result in accidental digital injections. Treatment recommendations and adverse outcomes are based on case reports. The objective of our study is to determine the frequency of digit ischemia after epinephrine autoinjector digital injections. In addition, we describe the frequency of epinephrine digital injections, treatments used, adverse local effects, and systemic effects. METHODS: We performed a retrospective cohort study on cases reported to 6 poison centers during 6 years, using a search of the Texas Poison Center Network database. Patients who had an epinephrine injection of the hand were reviewed, and digital injections were included. Variables collected included demographics, local and systemic effects, symptom duration, treatments used, comorbidities, and whether admission, surgery, or hand surgery consultation was used. One trained abstractor used a standard electronic data collection form. RESULTS: There were 365 epinephrine injections to the hand identified for the 6-year period. Of these, 213 were digital injections, and 127 had follow-up. All patients had complete resolution of symptoms. None of the patients were hospitalized or received hand surgery consultation or surgical care. Significant systemic effects were not reported. Pharmacologic vasodilatory treatment was used in 23% (29/127) of patients. Ischemic effects were documented for 4 patients, and 2 of these had symptom resolution within 2 hours. All 4 patients received vasodilatory therapy and were discharged home, with complete resolution of symptoms. CONCLUSION: In our series of patients using poison center calls about digital epinephrine autoinjections, there were no cases in which clinically apparent systemic effects were recorded and few patients had ischemia. No patient was admitted or had surgery. Most clinicians did not use vasodilation medications or techniques.

Post exposure prophylaxis of HIV transmission after occupational injuries in Queen Elizabeth Central Hospital, Blantyre, Malawi, 2003 - 2008.

Health care worker (HCW) in Malawi may acquire HIV infection through occupational injuries, in particular since HIV prevalence among inpatients and incidence of occupational injuries are high. A post exposure prophylaxis (PEP) programme for occupational injuries at Queen Elizabeth Central Hospital (QECH) commenced in 2003. We performed an audit of this programme from 2003 through 2008. 203 Occupational injuries were reported. The majority were needle stick injuries (76.3%). Half of the clients were in a training position. A dual ART regimen was most frequently prescribed. Triple therapy use increased over time and was more frequent in expatriate students. Many nurses and clinical officers were not fully vaccinated for HBV. Based on previous incidence data, occupational injuries were likely to be underreported. Data on side effects were incomplete, however PEP discontinuation due to side effects occurred only twice. Follow up visits were poorly attended, therefore the efficacy of PEP could not be evaluated. Prevention efforts for occupational injuries should be increased and specifically target HCWs in training positions. Measures to improve quality of the PEP programme include effective publicity campaigns, compulsory Hepatitis B vaccination and active tracing of HCWs who default follow up after PEP.

Needlestick and infection with horse vaccine.

This report describes a case of accidental needlestick injury involving a live equine vaccination, Equilis StrepE. A vet presented herself to the Emergency Department having accidentally injected herself with an equine vaccination. Her left thumb (injury site) was inflamed and had lymphangitis progressing proximally along her left arm. Her inflammatory markers were not raised. The swelling, erythma and lymphangitis had improved markedly with intravenous antibiotics. She had no sequelae at follow-up. Equilis StrepE is a vaccine for submucosal administration containing a modified live avirulent strain of Streptococcus equi subspecies equi (Strain TW). Group C streptococci infections are pathogenic in horses and uncommon in humans. A search of the literature revealed no prior case report of similar adverse reaction to this vaccine. The vaccine may have harmful effect on human health, if injected accidentally but more evidence needs to be collected.

HIV-1 infection of a nurse from a newborn with an unknown HIV infection: a case report.

BACKGROUND: HIV infection of healthcare workers by injury is an important issue in the management and prophylaxis of HIV-related disease. OBJECTIVES: To describe a case where a nurse has been HIV-1 infected by needle-stick whilst taking blood from a newborn with an unknown HIV infection. STUDY DESIGN: Virological, immunological and clinical analysis of a peculiar case of HIV transmission from newborn to nurse has been reported. RESULTS: The nurse has been infected by needle-stick injury whilst taking blood from a newborn with an unknown HIV infection. The delayed declaration of accident by nurse and the inaccurate medical management of pregnant woman determined the subsequent absence of correct prophylaxis measures and then the impossibility to tackle the HIV transmission. CONCLUSION: This case indicates that HIV serological screening of pregnant women and prompt accident notification by health-care workers represent basic preventive measures that should effectively tackle the spread of HIV infection.

The probability of HIV infection in a new host and its reduction with microbicides.

We use a simple mathematical model to estimate the probability and its time dependence that one or more HIV virions successfully infect target cells. For the transfer of a given number of virions to target cells we derive expressions for the probability P(inf), of infection. Thus, in the case of needlestick transfer we determine P(inf) and an approximate time window for post-exposure prophylaxis (PEP). For heterosexual transmission, where the transfer process is more complicated, a parameter gamma is employed which measures the strength of the infection process. For the smaller value of gamma, P(inf) is from 6 x 10(-5) to 0.93 or from 7.82 x 10(-6) to 0.29, where the lower figures are for the transfer of 100 virions and the upper figures are for the transfer of 4.4 million virions. We estimate the reductions in P(inf) which occur with a microbicide of a given efficacy. It is found that reductions may be approximately as stated when the number of virions transferred is less than about 10(5), but declines to zero for viral loads above that number. It is concluded that PEP should always be applied immediately after a needlestick incident. Further, manufacturers of microbicides should be encouraged to investigate and report their effectiveness at various transferred viral burdens.

The EpiPen and the ischaemic finger.

We present a case of a 24-year-old with a history of accidental injection of adrenaline from an EpiPen into the proximal aspect of her left index finger. Various methods were advocated to treat digital ischaemia but were of no benefit. Topical infiltration of phentolamine in 1 ml of lignocaine 2% was given at the puncture site with immediate results of resolution of digital ischaemia.

Prospective study of community needlestick injuries.

Fifty three children were referred following community needlestick injuries, August 1995 to September 2003. Twenty five attended for serology six months later. None were positive for HIV, or hepatitis B or C. Routine follow up after community needlestick injury is unnecessary. HIV post-exposure prophylaxis should only be considered in high risk children.

Food intake and oral sucrose in preterms prior to heel prick.

To investigate the soothing effect of feeding on infants in distress, the effects of 2 mL 15% and 1 mL 25% sucrose given orally 2 min before heel prick in fasting preterms to reduce the pain response were assessed. The effects of milk intake by nasogastric tube were also assessed once during the last hour before heel prick, and the effects of milk intake by nasogastric tube once during the last hour before heel prick together with 1 mL 25% sucrose given orally 2 min before heel prick. The pain response was measured as changes in crying time, behavioural state, skin conductance and heart rate. Each group included 12 healthy preterm infants with a median gestational age of 32 wk and a median postnatal age of 14 d. These infants were randomly studied twice; one in connection with the intervention and once after being given sterilized water. Differences in the measured variables before and during heel prick showed that only the crying time was reduced when the infants received milk or 25% sucrose prior to heel prick (p < 0.05). If the infants received milk and 25% sucrose before heel prick, the crying time and the level of behavioural state were reduced (p < 0.05). The increase from before to during heel prick in skin conductance (number and amplitude of the waves) and heart rate correlated with the crying time (p < 0.01).