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Background: Patients determined to have margin-positive nonmelanoma skin cancer (NMSC) after initial shave or punch biopsy performed by a primary care physician or dermatologist are commonly referred to extirpative surgeons for definitive removal. Not infrequently, the residual tumor is not appreciable, and the exact location of the lesion is indiscernible. The consulting surgeon must decide to excise the presumed lesion or clinically monitor for recurrence. Methods: This single-center, retrospective review examined patients with squamous and basal cell carcinomas referred over a 5-year period to two senior authors. Results: In total, 233 patients had a total of 312 lesions excised. Thirty-nine (12.5%) of these lesions (in 33 patients) demonstrated no residual tumor on pathologic examination. Twelve patients were managed nonoperatively (5.15%) and observed to have had no tumor recurrence with a mean observation period of 14.66 months (range 1-54 months). Thus, approximately 19.3% of all patients referred had no residual tumor. Conclusion: Based on our observations and low proclivity for metastases, nonoperative monitoring of NMSC may be a reasonable option for certain lesions less than 1 cm that are undiscernible at the time of referral.
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Sphingomonas paucimobilis usually exhibits low virulence likely secondary to its lack of lipopolysaccharide A. Infections caused by S. paucimobilis more commonly afflict immunocompromised patients. Some case reports document pneumonia, osteomyelitis, pyomyoma, and septic arthritis secondary to S. paucimobilis in immunocompetent patients. S. paucimobilis bacteremia is associated with underlying conditions, including malignancy, diabetes mellitus, end-stage renal disease, and chronic obstructive pulmonary disease. Bacteremia has the potential to lead to septic shock. Antimicrobial effectiveness varies, and the mechanism that leads to resistance has not yet been elucidated. This underscores the importance of antimicrobial susceptibility testing. We present a unique case of community-acquired S. paucimobilis bacteremia and resultant septic shock in an immunocompetent patient. A 90-year-old female with a history of chronic kidney disease, acute colonic infarction status post colostomy, gastroesophageal reflux disease, hypertension, supraventricular tachycardia, and schizoaffective disorder presented to the emergency department with hypotension and altered mental status. Urinalysis and chest X-ray were unremarkable. Antibiotic therapy with cefepime was initiated following gram stain, which showed gram-negative rods. The blood culture revealed S. paucimobilis. The patient was discharged with the plan to enter hospice care.
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Atopic dermatitis is a condition characterized by xerotic and pruritic skin. While the onset of the disease is usually in childhood, it may persist into adulthood. First-line treatments include adequate moisturization, avoidance of irritants, and the application of topical corticosteroids. Dupilumab is a biologic therapy, approved for moderate-to-severe atopic dermatitis, that dampens the pruritus sensation by inhibiting the downstream effects of the T helper cell type 2 pathway by binding to the interleukin-4 receptor α subunit. The monoclonal antibody is typically well-tolerated. We present a novel case of the development of generalized granuloma annulare after treatment with dupilumab. A 71-year-old male with a history of hypertension, hyperlipidemia, chronic kidney disease, gout, and bipolar disorder presented to clinic with biopsy-proven severe atopic dermatitis. First-line treatments had been exhausted, and the patient was not an ideal candidate for traditional systemic options secondary to his poor renal function. Therapy with dupilumab was initiated and continued for two years until the patient developed biopsy-proven generalized granuloma annulare. At this time, dupilumab was discontinued and the pharmaceutical company was made aware of this side effect.
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We present a case of a rare cause of gastric perforation and pneumoperitoneum, associated with Sarcina ventriculi. An 88-year-old male presented to the emergency room with significant abdominal pain as his chief complaint. Abdominal radiograph showed extensive free intraperitoneal gas under the diaphragms. Computed tomography (CT) of the abdomen and pelvis showed pneumatosis, portal venous gas, and extensive free intraperitoneal gas with free fluid. Immediate surgical intervention ensued. The gastric biopsies obtained proved valuable for confirming the diagnosis of S. ventriculi. In conjunction with surgery, the patient received a course of antibiotics for a cure.