Vancomycin flushing syndrome in orthopaedic practice: A case report.

BACKGROUND: Vancomycin flushing syndrome (VFS), also known as red man syndrome, is an allergic reaction to vancomycin. It typically presents as a rash on the face, neck, and upper torso after intravenous administration of vancomycin. VFS is blamed on rapid intravenous infusion of vancomycin during management and rarely happens after local use. A review of the literature showed that in the last 23 years, 4 such cases have been reported. Here, we add another case of VFS developed after slow local absorption of vancomycin in cement beads. CASE SUMMARY: A 44-year-old male with a known case of hypertension, no history of allergies to medications, and a history of chronic osteomyelitis of the right tibia with discharging sinus over the anterolateral aspect of the leg. The pus culture grew Staphylococcus aureus, which was sensitive to clindamycin and vancomycin. The patient underwent irrigation and debridement with the placement of vancomycin cement beads made from 4 g of vancomycin powder and 40 g of polymethyl methacrylate. Three hours postoperatively, the patient developed a pruritic, erythematous, macular rash predominantly on his face, neck, chest, and lower extremities and to a lesser extent his upper extremities. A diagnosis of VFS was made and was successfully treated with cetirizine (10 mg, oral) and methylprednisolone sodium succinate (125 mg, intravenous). The patient continued to have itching with a facial rash for 12 h with gradual improvement. A decision was made to not remove the beads as the patient continued to improve. Gradually, the rash disappeared after 96 h with no further sequela. CONCLUSION: VFS can occur not only after rapid intravenous injection of vancomycin but also with local release, as in our case. As orthopaedic surgeons routinely use vancomycin with polymethyl methacrylate in chronic osteomyelitis and revision arthroplasty, they should be aware of such a complication occurring.

Can we suppress excessive post-surgical scar formation: A case report.

BACKGROUND: Hypertrophic scars (HSs) formation is a complication that occurs after wounds heal with secondary intention and sometimes after clean surgical incisions. Many treatments are in vogue now with varying successes. Although the mechanism or mechanisms that cause a HS to form are not clearly understood, one thing that is clear is that once scar tissue matures, any intervention will not be successful. In this paper, we report on a case where a patient who was known to develop HS was treated with a new combination of ingredients (Phyto-chemicals + Silicone JUMI) to suppress HS formation. CASE SUMMARY: A 68-year-old female of African descent presented a severe HS post total knee replacement (TKR), which the patient describes as itchy and painful. Due to complications caused by the scar, she was apprehensive about undergoing TKR on her other knee. However, after the TKR of the contralateral side post-removal of skin clips, JUMI anti-scar cream (JASC) was used to suppress excessive scar formation. CONCLUSION: JASC appears potent and efficacious at suppressing excessive scar formation. We believe that this warrants further studies on larger patient groups and on different surgical sites.

Maintenance Dose of Vitamin D: How Much Is Enough?

BACKGROUND: It is still unclear the ideal vitamin D dosage once the deficiency and insufficiency is treated. Once deficiency was corrected we prospectively treated patients with 2,000 IU of vitamin D3 to check whether this dosage is enough to keep them above the 30 ng/mL of 25-hydroxy-vitamin D (25[OH]D). METHODS: One hundred and thirty-five Saudi Arabian men and women treatment naïve for the vitamin D deficiency and insufficiency were part of this study. History and clinical examination were done to rule out any metabolic bone disease. Weight and height was taken to calculate the body mass index (BMI). Patients who were vitamin D deficient (≥30 ng/mL), a standard treatment of 50,000 IU of vitamin D3 weekly for 3 months, a blood test for the vitamin D levels at the end of 3 months, maintenance dose of 2,000 IU of vitamin D3 for 3 months and a third blood sample after 3 months. RESULTS: The data for 128 patients was available for analysis. The average age was 44.95±12.97 years with the mean BMI of 29.60±2.59 kg/m2. The baseline 25(OH)D level was 13.16±3.30 ng/mL. The increase in the level of 25(OH)D on 50,000 IU weekly was significant from 13.16±3.3 ng/mL to 36.97±4.67 ng/mL (P<0.001) and then 2,000 IU daily for next 3 months, the level of 25(OH)D dropped top 20.38±5.42 ng/mL (P<0.001). CONCLUSIONS: Our study indicates that the maintenance dose of 2,000 IU of vitamin D is not enough for patients to keep the 25(OH)D levels above 30 ng/mL.