Experience with dalbavancin use in various gram-positive infections within Aberdeen Royal Infirmary OPAT service.

PURPOSE: Dalbavancin, approved in 2014 for Gram-positive acute bacterial skin and skin structure infections (ABSSSI), has pharmacokinetics enabling treatment with one or two doses. Dalbavancin might be useful in outpatient parenteral antibiotic therapy (OPAT) of deep-seated infections, otherwise requiring inpatient admission. We documented our experience with pragmatic dalbavancin use to assess its effectiveness for varied indications, on- and off-label, as primary or sequential consolidation therapy. METHODS: Patients prescribed dalbavancin between 1 December 2021 and 1 October 2022 were screened for demographics of age, sex, Charlson comorbidity index (CCI), allergies, pathogens, doses of dalbavancin, other antibiotics administered and surgery. Where available, infection markers were recorded. The primary outcome was a cure at the end of treatment. Secondary outcomes included any adverse events and for those with treatment failures, response to salvage antibiotics. RESULTS: Sixty-seven per cent of patients were cured. Cure rates by indication were 93% for ABSSSI, 100% for bacteraemia, 90% for acute osteomyelitis, 0% for chronic osteomyelitis, 75% for native joint septic arthritis and 33% for prosthetic joint infection. Most bone and joint infections that were not cured did not have source control, and the goal of treatment was suppressive. Successful suppression rates were greater at 48% for chronic osteomyelitis and 66% for prosthetic joint infections. Adverse events occurred in 14 of 102 patients. CONCLUSION: This report adds to clinical experience with dalbavancin for off-label indications whilst further validating its role in ABSSSI. Dalbavancin as primary therapy in deep-seated infections merits investigation in formal clinical trials.

HIV and skin infections.

HIV infection alters the skin microbiome and predisposes to a wide range of cutaneous infections, from atypical presentations of common skin infections to severe disseminated infections involving the skin that are AIDS-defining illnesses. Bacterial infection of the skin, most commonly caused by Staphylococcus aureus, occurs frequently and can result in bacteremia. Nontuberculous mycobacterial infections that are usually localized to the skin may disseminate, and guidance on the treatment of these infections is limited. Herpes simplex can be severe, and less common presentations such as herpetic sycosis and herpes vegetans have been reported. Severe herpes zoster, including disseminated infection, requires intravenous antiviral treatment. Viral warts can be particularly difficult to treat, and in atypical or treatment-resistant cases a biopsy should be considered. Superficial candidosis occurs very commonly in people living with HIV, and antifungal resistance is an increasing problem in non-albicans Candida species. Systemic infections carry a poor prognosis. In tropical settings the endemic mycoses including histoplasmosis are a problem for people living with HIV, and opportunistic infections can affect those with advanced HIV in all parts of the world. Most cutaneous infections can develop or worsen as a result of immune reconstitution in the weeks to months after starting antiretroviral therapy. Direct microscopic examination of clinical material can facilitate rapid diagnosis and treatment initiation, although culture is important to provide microbiological confirmation and guide treatment.

Características clínicas y microbiológicas de infecciones de piel y partes blandas en pacientes pediátricos de dos hospitales de Buenos Aires / Skin and soft tissue infections in pediatrics

Las infecciones de piel y partes blandas (IPPB) en niños son una de las principales causas de prescripción de antimicrobianos. El objetivo del estudio fue describir las características clínicas y microbiológicas de las IPPB ambulatorias de niños asistidos en dos hospitales zonales. Se realizó un estudio prospectivo entre el 1/11/2017 y el 1/11/2018. Se incluyeron pacientes entre 1 mes y 15 años internados en dos hospitales. Se evaluó: edad, sexo, localidad, factores predisponentes, tipo de IPPB, muestras biológicas realizadas, aislamiento microbiológico, tratamiento empírico indicado y evolución del cuadro. Se realizó antibiograma y determinación genética. Se calculó chi2, IC95, OR; α=5%. N= 94. 58,7% masculinos. 12 pacientes <1 año, 85 >1 año (promedio de edad 4 años, 1-15). El 36% de Tandil y 63,8% de Florencio Varela. El 59,6% corresponden a IPPB purulentas. Se aislaron microorganismos en un 59,6%. Los aislamientos principales: SAMR (40,4%), SAMS (7,4%), S. agalactiae (2,1%) y S. pyogenes (2,1%). El 100% de SAMR son portadores de gen mecA y SCCmec tipo IV, sin multirresistencia. No hubo diferencia estadística entre los factores de riesgo evaluados para el desarrollo de IPPB por SAMR. El 52,1% de los niños recibió tratamiento antibiótico combinado, siendo la más indicada TMS-SMX + CLI en 36 eventos. (38,3%). La evolución fue favorable: no hubo diferencia significativa entre el subgrupo que se aisló SAMR y el que no se aisló SAMR; 91,9% (34/37) y 92,6% (50/54) correspondientemente (chi2: 0,01; p= 0,97 IC95: 0,26-3,88). El principal agente etiológico fue SAMRco, debiendo adecuar los tratamientos a este microorganismo.

Skin and soft tissue infections (SSIs) in children are one of the main causes of antimicrobial prescription. The aim of the study was to describe the clinical and microbiological characteristics of outpatient SSIs in children attended in two hospitals. A prospective study was conducted between 11/1/2017 and 11/1/2018. Patients between 1 month and 15 years old, hospitalized were included. We evaluated: age, sex, locality, predisposing factors, type of IPPB, biological samples taken, microbiological isolation, empirical treatment indicated and evolution of the condition. An antibiogram and genetic determination were performed. Chi2, CI95, OR; α=5% were calculated. N= 94. 58.7% male. 12 patients <1 year, 85 >1 year (mean age 4 years, 1-15). 36% were from Tandil and 63.8% from Florencio Varela. 59.6% corresponded to purulent SSIs. The diagnostic yield was 59.6%. Main isolates: MRSA (40.4%), MSSA (7.4%), S. agalactiae (2.1%) and S. pyogenes (2.1%). 100% of MRSA carried the mecA gene and SCCmec type IV, with no multidrug resistance. There was no statistical difference between the risk factors evaluated. 52.1% of children received combined antibiotic treatment, the most indicated being TMS-SMX + CLI in 36 events. (38,3%). Evolution was favorable: there was no significant difference between the subgroup that isolated MRSA and the subgroup that did not isolate MRSA; 91.9% (34/37) and 92.6% (50/54) respectively (chi2: 0.01; p= 0.97 CI95: 0.26-3.88). The main etiological agent was MRSA, and treatments should be adapted to this microorganism

[Soft tissue infections]. / Weichgewebeinfektionen.

Acute skin and soft tissue infections are among the most frequent infections in medicine. There is a broad spectrum including simple local infections as well as severe and life-threatening diseases. Along with Staphylococcus aureus, group A Streptococci are mainly responsible for these illnesses. The therapeutic approach ranges from antiseptic local treatments to administering systemic antibiotics or emergency surgery. Treating physicians often face challenges when presented with soft tissue infections due to a great discrepancy between the first impression of the disease compared to a possibly quick progression as well as the wide range of sometimes confusing historic terms and definitions being used in the English and German language, for instance pyoderma, erysipelas or phlegmon. A recently more popular collective term emphasized by clinical trials is "acute bacterial skin and skin structure infections" (ABSSSI).

Enfrentamiento de las infecciones de piel en el adulto / Managing adult skin infections

En la actualidad, las infecciones de piel y partes blandas forman parte de un alto porcentaje de las consultas en salud. Estas van desde infecciones leves, donde el manejo se realiza con tratamiento tópico, hasta aquellas con severo compromiso sistémico, requiriendo terapia antibiótica sistémica e incluso el desbridaje quirúrgico. En general, son producto de un desbalance entre los mecanismos de defensa de la barrera cutánea y los factores de virulencia y patogenicidad de los microorganismos que la afectan. Se pueden clasificar según distintos criterios, como por ejemplo, profundidad, gravedad, microorganismos involucrados y si estas son purulentas o no. El reconocer estas entidades clínicas es de suma importancia para llevar a cabo un adecuado tratamiento en los pacientes que presentan estas afecciones, ya que los diagnósticos erróneos llevan a las múltiples consultas con el consiguiente aumento de costos asociados en atención en salud.

Currently, skin and soft tissue infections are part of a high percentage of health consultations. These range from mild infections, where management is performed with topical treatment, to those with severe systemic compromise requiring systemic antibiotic therapy and even surgical debridement. In general, they are the product of an imbalance between the defense mechanisms of the skin barrier and the virulence and pathogenicity factors of the microorganisms that affect it, which can vary from bacterial, viral, fungal and parasites agents. Skin and soft tissue infections can be classified according to different criteria, such as depth, severity, microorganisms involved and whether they are purulent or not. Recognizing these clinical entities is of utmost importance to carry out adequate treatment in patients with these conditions, since erroneous diagnoses lead to multiple consultations with the consequent increase in costs associated with health care

The role of procalcitonin in reducing antibiotics across the surgical pathway.

Procalcitonin (PCT) is widely considered as a highly sensitive biomarker of bacterial infection, offering general and emergency surgeons a key tool in the management of surgical infections. A multidisciplinary task force of experts met in Bologna, Italy, on April 4, 2019, to clarify the key issues in the use of PCT across the surgical pathway. The panelists presented the statements developed for each of the main questions regarding the use of PCT across the surgical pathway. An agreement on the statements was reached by the Delphi method, and this document reports the executive summary of the final recommendations approved by the expert panel.

Effective Treatment of Cutaneous Mold Infections by Antimicrobial Blue Light That Is Potentiated by Quinine.

BACKGROUND: Cutaneous mold infections commonly result from an array of traumatic injuries that involve direct inoculation of contaminated soil into wounds. Here, we explored the use of antimicrobial blue light (aBL; 405 nm wavelength) and the combination of aBL with quinine hydrochloride (aBL + Q-HCL) for the treatment of cutaneous mold infections. METHODS: Efficacy of aBL and aBL + Q-HCL in killing clinically important pathogenic molds (Aspergillus fumigatus, Aspergillus flavus, and Fusarium oxyprorum) was investigated. Ultraperformance liquid chromatography identified and quantified endogenous porphyrins in the mold conidia. Finally, a mouse model of dermabrasion wound infected with a bioluminescent variant of A. fumigatus was developed to investigate the efficacy of aBL in treating cutaneous mold infections. RESULTS: We demonstrated that mold conidia are tolerant to aBL, but Q-HCL enhances efficacy. Transmission electron microscopy revealed intracellular damage by aBL. aBL + Q-HCL resulted in intracellular and cell wall damage. Porphyrins were observed in all mold strains, with A. fumigatus having the highest concentration. aBL and aBL + Q-HCL effectively reduced the burden of A. fumigatus within an established dermabrasion infection and limited recurrence posttreatment. CONCLUSIONS: aBL and aBL + Q-HCL may offer a novel approach for the treatment of mold infections.

Antimicrobial Dosing in Specific Populations and Novel Clinical Methodologies: Obesity.

Obesity and its related comorbidities can negatively influence the outcomes of certain infectious diseases. Specific dosing recommendations are often lacking in the product label for patients with obesity that leads to unclear guidance in practice. Higher rates of therapeutic failure have been reported with some fixed dose antibiotics and pragmatic approaches to dose modification are limited for orally administered agents. For i.v. antimicrobials dosed on weight, alternate body size descriptors (ABSDs) have been used to reduce the risk of overdosing. These ABSDs are mathematical transformations of height and weight that represent fat-free weight and follow the same principles as body surface area (BSA)-based dosing of cancer chemotherapy. However, ABSDs are rarely studied in pivotal phase III studies and so can risk the underdosing of antimicrobials in patients with obesity when incorrectly applied in the real-world setting. Specific case examples are presented to highlight these risks. Although general principles may be considered by clinicians, a universal approach to dose modification in obesity is unlikely. Studies that can better distinguish human body phenotypes may help reduce our reliance on height and weight to define dosing. Simple and complex technologies exist to quantify individual body composition that could improve upon our current approach. Early evidence suggests that body composition parameters repurposed from medical imaging data may improve upon height and weight as covariates of drug clearance and distribution. Clinical trials that can integrate human body phenotyping may help us identify new approaches to optimal dose selection of antimicrobials in patients with obesity.

5-Fluorouracil in Dermatology: The Diverse Uses Beyond Malignant and Premalignant Skin Disease.

BACKGROUND: 5-fluorouracil (5-FU) is widely used for treatment of malignant and premalignant skin cancers; however, its use in other common cutaneous conditions has been less widely reported. OBJECTIVE: We investigated the off-label uses of 5-FU beyond malignant and premalignant skin disease. METHODS: We conducted a literature review searching multiple databases to evaluate the evidence for the off-label uses of 5-FU. The level of evidence was evaluated and selected accordingly listing the studies with the highest level of evidence first using the Oxford Centre of Evidence-Based Medicine 2011 guidance. RESULTS: We found underlying evidence to support the use of 5-FU for a wide range of noncancerous cutaneous indications including scarring (keloid, hypertrophic), pigmentary disorders (vitiligo, idiopathic guttate hypomelanosis), cutaneous infections (viral warts, molluscum contagiosum), inflammatory dermatoses (Darier's disease, Hailey-Hailey disease and sarcoidosis), and cosmetic indications (photoaging, treatment of filler nodules and granulomas). CONCLUSION: In selected patients, 5-FU can be as effective as more established treatments, with fewer side-effects.

A Critical Reappraisal of Off-Label Use of Photodynamic Therapy for the Treatment of Non-Neoplastic Skin Conditions.

BACKGROUND: In the past 30 years, topical photodynamic therapy (PDT) has been investigated for the treatment of a broad spectrum of cosmetic, inflammatory, and infectious skin conditions with variable, and often contrasting, results. However, the non-expert clinician may be in difficulty evaluating these results because different sensitizers, concentrations, formulations, light sources, and irradiation protocols have been used. In addition, many of these studies have poor quality design being case reports and uncontrolled studies of few cases. SUMMARY: With the aim to clarify the potential usefulness of PDT for the treatment of infectious and inflammatory skin diseases as well as selected cosmetic indications, we searched for randomized controlled clinical trials, non-randomized comparative studies, retrospective studies, and case series studies with a number of at least 10 patients, published since 1990. Later, we reappraised the results in order to give a simple critical overview. Key Messages: Evidence from the literature seems to strongly support the use of ALA- and MAL-PDT for the treatment of common skin diseases such as acne, warts, condylomata, and Leishmania skin infection and for photorejuvenation, i.e., the correction of selected cosmetic changes of aging and photoaging. For other disorders, the level of evidence and strength of recommendation are lower, and controlled randomized studies with prolonged follow-ups are necessary in order to assess the clinical usefulness and other potential advantages over current treatment options.

Complicated Posterior Cervical Skin and Soft Tissue Infections at a Single Referral Center.

BACKGROUND: Although the incidence and mortality of complicated skin and soft tissue infections have decreased, this infection is still relatively frequent and can be associated with lethal complications. In this study, the authors present our clinical experience of patients with complicated posterior cervical skin and soft tissue infections (CPCSSTIs) diagnosed and treated in a reconstructive unit in northeastern China. METHODS: A retrospective chart review of patients diagnosed with CPCSSTIs from January 2009 to December 2018 was performed. To make the results objective and convincing, a data analysis was performed relating to demographic characteristics, clinical presentation, predisposing factor, bacterial culture, laboratory and radiographic evaluations, diagnostic clues, management, and complications as well as the clinical course and outcome. RESULTS: During the ten-year period, there were 174 consecutive patients admitted to our reconstructive center with final diagnosis of CPCSSTIs included. All the patients were adults, and the majority were male (67.2%). The patient's mean age was 51.3 years (range, 15-88 years). There were 114 patients (65.5%) that had associated systemic diseases, with diabetes mellitus (40.2%) as the most common predisposing factor. Common presented clinical symptoms were pain (90.8%), swelling (85.1%), and erythema (77%) of the neck. Surgical treatment was performed in all the patients, and most of them (83.9%) received the first surgery within 24 h. The most commonly isolated pathogen was Staphylococcus aureus (30%). Vancomycin (21.3%) was the most commonly used antibiotics, followed by cefepime (18.4%). All the patients survived and were discharged with a mean duration of hospitalization of 28.7 days. Those patients with predisposing factors (31.4 ± 12.35 days) or complications (41.0 ± 12.5 days) tended to have a longer hospital stay. The mean total costs of admission per patient were 47 644 RMB. CONCLUSION: This study highlights the high cost burden of CPCSSTI patients. Those patients with predisposing factors or complications tended to have a longer hospital stay.

Morbilidad por infecciones de partes blandas superficiales en el servicio de clínicas pediátricas de Manzanillo, Granma 2018 / Morbidity caused by soft tissue infections in the services of pediatric clinic in Manzanillo, Granma, 2018

RESUMEN Introducción: Las infecciones de la piel y partes blandas son frecuentes en los niños, con un amplio espectro de gravedad. Objetivo: Describir las características clínico-epidemiológicas de los pacientes con infecciones de partes blandas superficiales hospitalizados en el servicio de clínicas pediátricas del Hospital Pediátrico Docente "Hermanos Cordové". Método: Se realizó un estudio observacional, descriptivo y transversal en el servicio de clínicas pediátricas del Hospital Pediátrico Docente "Hermanos Cordové", de Manzanillo durante el 2018.Se estudiaron todos los pacientes egresados (n=298) con el diagnóstico confirmado de este tipo de infecciones. Se tomaron en cuenta las siguientes variables: localización anatómica, clasificación del tipo deinfección de piel y tejidos blandos, terapéutica utilizada y estadía hospitalaria. Resultados: Predominó el sexo masculino (57,7 %) y el grupo de edad de 10-14 años (34,9 %). Las infecciones en las extremidades estuvieron presentes en 113 pacientes (37,9 %). El impétigo fue la entidad clínica más frecuente (42,3 %), la cefazolina fue el antibiótico más utilizado (77,2 %). Se observó que la mayoría de los pacientes (293) solo permaneció hasta 7 días ingresados, con una evolución satisfactoria. Conclusiones: En el servicio de clínicas pediátricas del Hospital Pediátrico Docente "Hermanos Cordové", los pacientes con IPTB se caracterizan por ser sobre todo varones, más comúnmente con edad entre 10 y 14 años, las lesiones predominaron en las extremidades y la más común fue el impétigo. La cefazolina resultó eficaz para el tratamiento estas infecciones, lo que hizo posible que la estadía hospitalaria generalmente no excediera de siete días.

ABSTRACT Introduction: Infections in the skin and soft tissues are common health concerns in children, with a wide range of severity from patient to patient. Objective: To describe the clinical-epidemiological characteristics of the patients with soft tissue infections hospitalized in the Pediatric Teaching Hospital "Hermanos Cordové". Method: An observational, descriptive, cross-sectional study was carried out in the services of pediatric clinic in the Pediatric Teaching Hospital "Hermanos Cordové", in Manzanillo, Cuba, during the year 2018. All discharged patients who had a confirmed diagnosis of this type of infection were studied (n=298). The following variables were taken into account: anatomical location, classifications of the different types of skin and soft tissue infections, treatment used and hospitalization. Results: Male gender prevailed in the patients (57.7 %), and also the ages ranging between 10 to 14 years old (34.9 %). Infections located on the limbs were described in 113 patients (37.9 %). Impetigo was the most common diagnosis (42.3 %), and the most frequently used antibiotic was cefazolin (77.2 %). Most of the patients were hospitalized up to 7 days (293), with a satisfactory evolution of the disease. Conclusions: Patients with soft tissue infections in the services of pediatric clinic in the Pediatric Teaching Hospital "Hermanos Cordové" are mainly characterized for being male, especially from ages raging between 10 to 14 years old, with impetigo being the most common infection, mostly located on the limbs. Cefalozin resulted very effective for the treatment of these infections, making possible the hospitalization time to be lesser than a week.

Emergence of Fungal-Like Organisms: Prototheca.

The genus Prototheca consists of achlorophyllic algae that are ubiquitous in the environment and animal intestines. However, this organism has forfeited its photosynthetic ability and switched to parasitism. In 1894, Krüger described two microorganisms isolated in Germany from mucous flux of Tilia and Ulmus spp., namely Prototheca moriformis and P. zopfii. Based on their yeast-like colony morphology, Krüger classified these organisms as fungi. The genus is now included within the class Trebouxiophyceae, order Chlorellales, and family Chlorellaceae. Historically, protothecosis and infections caused by green algae have been studied in the field of medical mycology. Prototheca spp. have been found to colonize human skin, fingernails, the respiratory tract, and digestive system. Although human infection by Prototheca is considered rare, an increase in infections has been noted among immunosuppressed patients, those on corticosteroid treatment, or both. Moreover, the first human outbreak of protothecal algaemia and sepsis was recently reported in a tertiary care chemotherapy oncology unit in 2018. Prototheca is also a causative pathogen of bovine disease. Prototheca zopfii and P. blaschkeae are associated with bovine mastitis, which causes a reduction in milk production and secretion of thin, watery milk containing white flakes. Economic losses are incurred either directly via reduced milk production and premature culling of affected animals or indirectly as a result of treatment and veterinary care expenses. Thus, knowledge of this fungal-like pathogen is essential in human and veterinary medicine. In this mini-review, I briefly introduce human and animal protothecoses.

Formaldehyde as an alternative to antibiotics for treatment of refractory impetigo and other infectious skin diseases.

Introduction: Antibiotic-resistant strains of bacteria are an increasing problem in hospitals and in the community. This has resulted in bacterial infections such as impetigo becoming difficult to treat. Alternative treatment options are needed. Areas covered: In this paper, a past study that assessed the health burden of scabies in North Queensland is described and from it, the potential for formaldehyde as an alternative antimicrobial treatment is discussed. In doing so, antibiotic resistance, impetigo, permethrin, and formaldehyde are introduced and the current understanding and limitations of the effects of formaldehyde on humans are outlined. The limited cases of formaldehyde resistance in bacteria are also discussed. Expert opinion: Formaldehyde is currently used as a preservative in cosmetics and medicinal creams due to its antibacterial activity. It, therefore, has the potential to be used as an alternative antibacterial treatment for infections with antibiotic-resistant bacteria. The harmful side effects of airborne formaldehyde and exposure in allergic individuals have been extensively studied. Significantly less research has been conducted on formaldehyde skin contact in healthy individuals. If formaldehyde is safe for topical use in humans, it has the potential to assist with combating antibiotic resistance.

Isolation of Phage Lysins That Effectively Kill Pseudomonas aeruginosa in Mouse Models of Lung and Skin Infection.

Multidrug resistance (MDR) is rapidly increasing in prevalence among isolates of the opportunistic pathogen Pseudomonas aeruginosa, leaving few treatment options. Phage lysins are cell wall hydrolases that have a demonstrated therapeutic potential against Gram-positive pathogens; however, the outer membrane of Gram-negative bacteria prevents most lysins from reaching the peptidoglycan, making them less effective as therapeutics. Nevertheless, a few lysins from Gram-negative bacterial phage can penetrate the bacterial outer membrane with the aid of an amphipathic tail found in the molecule's termini. In this work, we took a phylogenetic approach to systematically identify those lysins from P. aeruginosa phage that would be most effective therapeutically. We isolated and performed preliminary characterization of 16 lysins and chose 2 lysins, PlyPa03 and PlyPa91, which exhibited >5-log killing activity against P. aeruginosa and other Gram-negative pathogens (particularly Klebsiella and Enterobacter). These lysins showed rapid killing kinetics and were active in the presence of high concentrations of salt and urea and under pH conditions ranging from 5.0 to 10.0. Activity was not inhibited in the presence of the pulmonary surfactant beractant (Survanta). While neither enzyme was active in 100% human serum, PlyPa91 retained activity in low serum concentrations. The lysins were effective in the treatment of a P. aeruginosa skin infection in a mouse model, and PlyPa91 protected mice in a lung infection model, making these lysins potential drug candidates for Gram-negative bacterial infections of the skin or respiratory mucosa.

Infective dermatitis associated with HTLV-1 infection in a girl from Trinidad: Case report and review of literature.

Infective dermatitis (ID) associated with Human T-cell leukemia virus type-1 (HTLV-1) is a rare form of severe superinfected eczema seen mostly in the Caribbean islands and Latin America. Although rapid response to antibiotic treatment is observed, patients should be monitored for development of complications associated with this retroviral infection, including T-cell leukemia/lymphoma (ATLL) and HTLV-1 associated myelopathy/tropical spastic paraparesis (HAM/TSP). Infective dermatitis is rarely seen in the United States and therefore may be under-recognized by physicians unfamiliar with this condition. Herein, we present an additional case report of an ID associated with HTLV-1 in an 11-year-old girl from Trinidad.

Unusual case of cellulitis due to primary cutaneous histoplasmosis.

A 63-year-old white man with a history of rheumatoid arthritis on adalimumab was admitted to the hospital for left arm swelling and erythema. On physical examination, the patient was afebrile and non-toxic appearing and there was tense oedema of the left forearm. Initial laboratory work was unremarkable except for elevated inflammatory markers. MRI of the arm showed non-specific findings of inflammation. The patient was started on empiric antibiotics but did not improve. Given the patient's immunosuppression, early consideration was given to fungal or mycobacterial causes. Initial serum fungal studies were negative and the patient was taken for diagnostic local incision and biopsy of the left volar forearm. Grocott's methenamine silver and periodic acid-Schiff staining revealed fungal organisms resembling Histoplasma and intraoperative fungal cultures grew Histoplasma capsulatum confirming the diagnosis. The patient was treated with a 6-month course of itraconazole with improvement in his condition and eventual complete resolution.

An unusual location of squamous cell carcinoma and a rare cutaneous infection caused by serratia marcescens on the tumoral tissue: A case report.

RATIONALE: Serratia marcescens (S. marcescens) is an opportunistic pathogen of the Enterobacteriaceae family. Although S. marcescens is known to cause sepsis, meningitis, endocarditis, urinary system and ocular infections, skin infections are sporadic. Squamous cell carcinoma (SCC) is the most aggressive skin cancer type that is often located in the head and neck region, and rarely in the scalp tissue. PATIENT CONCERNS: An 89-years-old male patient was diagnosed with SCC three years ago. The frontal region of the skull showed an ulcerated tumor, irregular borders, and exophytic growth pattern. The destruction of the frontal bone made the vibrating brain tissue visible, and the lower part had haemopurulent flow. DIAGNOSES: Gram staining showed the proliferation of gram (-) bacilli. Bacteria were identified as non-pigmented S. marcessens in the wound culture. To the best of our knowledge, there have not been any cases reported with S. marcescens causing cutaneous infections on SCC. Therefore, our report is the first case in the literature. INTERVENTIONS: According to the culture antibiogram, S. marcescens was ciprofloxacin sensitive. Consequently, 1000 mg/day ciprofloxacin was initiated for 14 days. OUTCOMES: Purulent exudate in skin cancers may be caused by the nature of carcinoma tissue as well as the colonization of opportunistic pathogen microorganisms as seen in our patient. LESSONS: Examination of the wound cultures and elimination of infections are critical in these cases.