Laboratory diagnostics, phylogenetic analysis and clinical outcome of a subcutaneous Mycoleptodiscus indicus infection in an immunocompetent cat.

BACKGROUND: Mycoleptodiscus indicus is a dematiaceous hyphomycete fungus found on plant leaves. It has been rarely reported as a cause of human or animal disease, possibly because it is difficult to culture and identify from clinical specimens. Infections are presumably acquired by traumatic implantation. CASE PRESENTATION: An 8-year-old non-immunosuppressed cat from Georgia, USA, presented with a left front leg swelling without lameness. Cytology from a fine needle aspirate revealed pyogranulomatous inflammation with both cytoplasmic and extracellular fungal elements. There were septate hyphae with irregularly sized segments, non-staining uneven walls, and rounded yeast-like forms from which longer hyphae arose in a hub-and-spoke pattern. A mold was isolated on agar from a fine needle aspirate collected 1 week later and identified as M. indicus by morphology, DNA sequencing and phylogenetic analysis. The cat recovered completely and uneventfully with antifungal treatment. CONCLUSIONS: We report a previously undescribed presentation of M. indicus causing a subcutaneous infection in a cat with successful antifungal treatment. In this study we highlight the potential of M. indicus to infect immunocompetent animals, and the veterinary medical community should be aware of its unusual but characteristic clinical, microbiological and cytologic presentation.

Skin and Soft Tissue Infections Caused by Mycobacterium chelonae: More Common Than Expected?

Mycobacterium chelonae is a rapidly growing non-tuberculous mycobacterium, which causes infections of the human skin and soft tissue. Despite an increasing incidence of such infections, patients are often misdiagnosed. We report here 5 patients with cutaneous and/or soft tissue infection due to M. chelonae who were diagnosed and treated at our centre. Two of the 5 patients were on immunosuppressive treatment. While clinical presentations differed in each patient, all had a long history of skin lesions. In addition to careful history-taking, tissue biopsies were obtained for mycobacterial culture and histopathological examination. Culture-directed antibiotic therapy was initiated, which resulted in a slow, but continuous, healing of the lesions. In summary, M. chelonae infections are still relatively rare, but should be considered in both immunocompromised and immunocompetent patients with prolonged skin lesions resistant to standard antibiotic treatment. For diagnosis, tissue analysis for mycobacterial culture and histopathological examination, and once diagnosed, adequate antibiotic treatment, is needed.

Heterogeneity in FoxP3- and GARP/LAP-Expressing T Regulatory Cells in an HLA Class II Transgenic Murine Model of Necrotizing Soft Tissue Infections by Group A Streptococcus.

Invasive group A streptococcus (GAS) infections include necrotizing soft tissue infections (NSTI) and streptococcal toxic shock syndrome (STSS). We have previously shown that host HLA class II allelic variations determine the risk for necrotizing fasciitis (NF), a dominant subgroup of NSTI, and STSS by modulating responses to GAS superantigens (SAgs). SAgs are pivotal mediators of uncontrolled T-cell activation, triggering a proinflammatory cytokine storm in the host. FoxP3-expressing CD4+ CD25+ T regulatory cells (Tregs) comprise phenotypically and functionally heterogeneous subsets with a profound ability to suppress inflammatory responses. Specifically, activated Tregs, which express glycoprotein A repetitions predominant (GARP) and display latent transforming growth factor ß1 (TGF-ß1) complexes (latency-associated peptide [LAP]), exhibit strong immunosuppressive functions. The significance of Tregs that may participate in suppressing inflammatory responses during NSTI is unknown. Here, we phenotypically characterized FoxP3/GARP/LAP-expressing Tregs in GAS-infected or SAg (SmeZ)-stimulated splenocytes from transgenic (tg) mice expressing human HLA-II DRB1*15 (DR15 allele associated with nonsevere NF/STSS-protective responses) or DRB1*0402/DQB1*0302 (DR4/DQ8 alleles associated with neutral risk for combined NF/STSS). We demonstrated both in vivo and in vitro that the neutral-risk allele upregulates expression of CD4+ CD25+ activated effector T cells, with a significantly lower frequency of Foxp3+/GARP+ LAP- but higher frequency of Foxp3- LAP+ Tregs than seen with the protective allele. Additional in vitro studies revealed that the presentation of SmeZ by the neutral-risk allele significantly increases proliferation and expression of effector cytokines gamma interferon (IFN-γ) and interleukin-2 (IL-2) and upregulates CD4+ CD25+ T cell receptors (TCRs) carrying specific Vß 11 chain (TCRVß11+) T cells and Th1 transcription factor Tbx21 mRNA levels. Our data suggest that neutral-risk alleles may drive Th1 differentiation while attenuating the induction of Tregs associated with suppressive function.

Correlation between nasal microbiome composition and remote purulent skin and soft tissue infections.

The incidence of skin and soft tissue infections (SSTIs) has increased dramatically over the past decade, resulting in significant morbidity in millions of otherwise healthy individuals worldwide. Certain groups, like military personnel, are at increased risk for SSTI development. Although nasal colonization with Staphylococcus aureus is an important risk factor for the development of SSTIs, it is not clear why some colonized individuals develop disease while others do not. Recent studies have revealed the importance of microbial diversity in human health. Therefore, we hypothesized that the nasal microbiome may provide valuable insight into SSTI development. To examine this hypothesis, we obtained anterior-naris samples from military trainees with cutaneous abscesses and from asymptomatic (non-SSTI) participants. We also obtained samples from within abscess cavities. Specimens were analyzed by culture, and the microbial community within each sample was characterized using a 16S sequencing-based approach. We collected specimens from 46 non-SSTI participants and from 40 participants with abscesses. We observed a significantly higher abundance of Proteobacteria in the anterior nares in non-SSTI participants (P < 0.0001) than in participants with abscesses. Additionally, we noted a significant inverse correlation between Corynebacterium spp. and S. aureus (P = 0.0001). The sensitivity of standard microbiological culture for abscesses was 71.4%. These data expand our knowledge of the complexity of the nasal and abscess microbiomes and potentially pave the way for novel therapeutic and prophylactic countermeasures against SSTI.

The roles of injury and nonsteroidal anti-inflammatory drugs in the development and outcomes of severe group A streptococcal soft tissue infections.

PURPOSE OF REVIEW: This review summarizes clinical and basic science evidence linking trauma and nonsteroidal anti-inflammatory drug (NSAID) use to initiation and progression of severe group A streptococcal (GAS) soft tissue infection. RECENT FINDINGS: New evidence includes recent clinical series and controlled studies that lend support to an NSAID/GAS association, basic science studies that demonstrate unique roles for nonpenetrating injury and NSAID administration in initiation of cryptogenic GAS infection and experimental studies showing that nonselective NSAIDs accelerate disease progression and limit antibiotic efficacy in established GAS soft tissue infections. Potential mechanisms for these processes are discussed. SUMMARY: NSAIDs are important anti-inflammatory and analgesic drugs; however, new experimental data suggest that nonselective NSAIDs do more than simply mask the signs and symptoms of developing GAS infection. A more thorough understanding of the triadic interplay of injury-triggered immune signaling, GAS soft tissue infection and NSAIDs is of significant clinical importance and could shift the current paradigm of pain management to avert the consequences of such devastating infections.

Cyclic neutropenia with a novel gene mutation presenting with a necrotizing soft tissue infection and severe sepsis: case report.

BACKGROUND: Cyclic neutropenia is a rare disease. We report a 31-month-old girl with congenital cyclic neutropenia with a novel mutation in the ELANE gene who developed an acute necrotizing soft-tissue infection on her left axillary legion. CASE PRESENTATION: A 31-month-old girl was admitted to our pediatric emergency room because of a necrotizing soft tissue infection of the left axillary area. The infection progressed rapidly and resulted in septic shock. Despite a medical treatment and surgical debridement, the sepsis was not controlled, and severe inflammation developed. After applying of negative-pressure wound therapy, her clinical symptoms improved. Finally, she was diagnosed with cyclic neutropenia with a novel genetic mutation. One month after admission, she was discharged with a completely recovered wound and no need for skin grafting. CONCLUSION: Both adequate medical treatment and effective control of the source of infection are critically important to reduce morbidity in such complex cases of necrotizing fasciitis as appeared in an immunocompromised pediatric patient.

The phosphoenolpyruvate phosphotransferase system in group A Streptococcus acts to reduce streptolysin S activity and lesion severity during soft tissue infection.

Obtaining essential nutrients, such as carbohydrates, is an important process for bacterial pathogens to successfully colonize host tissues. The phosphoenolpyruvate phosphotransferase system (PTS) is the primary mechanism by which bacteria transport sugars and sense the carbon state of the cell. The group A streptococcus (GAS) is a fastidious microorganism that has adapted to a variety of niches in the human body to elicit a wide array of diseases. A ΔptsI mutant (enzyme I [EI] deficient) generated in three different strains of M1T1 GAS was unable to grow on multiple carbon sources (PTS and non-PTS). Complementation with ptsI expressed under its native promoter in single copy was able to rescue the growth defect of the mutant. In a mouse model of GAS soft tissue infection, all ΔptsI mutants exhibited a significantly larger and more severe ulcerative lesion than mice infected with the wild type. Increased transcript levels of sagA and streptolysin S (SLS) activity during exponential-phase growth was observed. We hypothesized that early onset of SLS activity would correlate with the severity of the lesions induced by the ΔptsI mutant. In fact, infection of mice with a ΔptsI sagB double mutant resulted in a lesion comparable to that of either the wild type or a sagB mutant alone. Therefore, a functional PTS is not required for subcutaneous skin infection in mice; however, it does play a role in coordinating virulence factor expression and disease progression.

Haemolysin Ahh1 secreted from Aeromonas dhakensis activates the NLRP3 inflammasome in macrophages and mediates severe soft tissue infection.

Severe soft tissue infections caused by Aeromonas dhakensis, such as necrotizing fasciitis or cellulitis, are prevalent in southern Taiwan and around the world. However, the mechanism by which A. dhakensis causes tissue damage remains unclear. Here, we found that the haemolysin Ahh1, which is the major virulence factor of A. dhakensis, causes cellular damage and activates the NLR family pyrin domain containing 3 (NLRP3) inflammasome signalling pathway. Deletion of ahh1 significantly downregulated caspase-1, the proinflammatory cytokine interleukin 1ß (IL-1ß) and gasdermin D (GSDMD) and further decreased the damage caused by A. dhakensis in THP-1 cells. In addition, we found that knockdown of the NLRP3 inflammasome confers resistance to A. dhakensis infection in both THP-1 NLRP3-/- cells and C57BL/6 NLRP3-/- mice. In addition, we demonstrated that severe soft-tissue infections treated with antibiotics combined with a neutralizing antibody targeting IL-1ß significantly increased the survival rate and alleviated the degree of tissue damage in model mice compared control mice. These findings show that antibiotics combined with therapies targeting IL-1ß are potential strategies to treat severe tissue infections caused by toxin-producing bacteria.

Linezolid desensitization for a patient with multiple medication hypersensitivity reactions.

OBJECTIVE: To describe a case in which a linezolid desensitization protocol was successfully used for a polymicrobial surgical wound infection in a patient with multiple drug hypersensitivity reactions. CASE SUMMARY: A 24-year-old woman with vocal cord dysfunction requiring tracheostomy was admitted for a surgical wound infection following a tracheostomy fistula closure procedure. The patient reported multiple antibiotic allergies including penicillins (rash), sulfonamides (rash), vancomycin (anaphylaxis), azithromycin (rash), cephalosporins (anaphylaxis), levofloxacin (unspecified), clindamycin (unspecified), and carbapenems (unspecified). Gram stain of the purulent wound drainage demonstrated mixed gram-negative and gram-positive flora, and bacterial cultures were overgrown with Proteus mirabilis, which precluded identification of other pathogens. Following failed test doses of linezolid, tigecycline, and daptomycin, all of which resulted in hypersensitivity reactions, a 16-step linezolid desensitization protocol was developed and successfully implemented without adverse reactions. The patient completed a 2-week course of antibiotic therapy that included linezolid upon finishing the desensitization protocol. DISCUSSION: Linezolid is useful in treating complicated and uncomplicated skin and soft tissue infections caused by gram-positive bacteria. With precautions, including premedication, a monitored nursing unit, and immediate availability of an emergency anaphylaxis kit, drug desensitization allows patients the ability to safely use medications to which they may have an immediate hypersensitivity reaction. Minimal data exist on linezolid desensitization protocols. CONCLUSIONS: Linezolid desensitization can be a viable option in patients requiring antimicrobial therapy for complicated gram-positive skin infections.

Methicillin-resistant Staphylococcus aureus (MRSA) infections among HIV-infected persons in the era of highly active antiretroviral therapy: a review of the literature.

OBJECTIVES: Despite the rise of methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infections (SSTIs) among HIV-infected persons during the era of highly active antiretroviral therapy (HAART), the precise relationship between these two infections has not been fully elucidated. Therefore, we provide a comprehensive, literature-based review of MRSA infections among HIV-infected persons. METHODS: A systematic search of MEDLINE using the search terms "HIV" and "MRSA" identified references published during the HAART era (January 1996 to January 2011). Relevant articles on MRSA in the general population were also reviewed for comparison. RESULTS: The most common type of MRSA infection among HIV-infected persons is SSTI caused by USA300, Panton-Valentine leukocidin (PVL)-positive strains. HIV-infected persons have an increased risk for both initial MRSA infections and recurrent infections compared with the general population. Risk factors for MRSA infections in this population include immunosuppression, comorbid conditions and certain lifestyle behaviours such as high-risk sexual behaviours and illicit drug use. Further research is needed on the optimal treatment and prevention strategies for MRSA infections among HIV-infected persons. CONCLUSIONS: HIV-infected persons have a propensity for MRSA SSTI and a high rate of recurrent disease. The reasons for the elevated rates of MRSA infections among HIV-infected persons appear to be multifactorial, but may be mitigated with optimized HIV control and reductions in associated risk factors.

[Humoral immune response in patients with angina and soft tissue infections of group a streptococci etiology].

AIM: Evaluate informativity of simultaneous determination of antibodies (AB) against extracellular (AB against streptolysin-O-ASL-O) and cellular (IgM against A-polysaccharide - A-PSC) antigens in patients with angina and soft tissue infections caused by serogroup A streptococci (SGA) and identify features of humoral immune response to SGA infection according to infectious process localization. MATERIALS AND METHODS. 2 groups of patients with bacteriologically confirmed SGA infection (50 cases of angina - group 1 and 51 case of soft tissue infection - group 2) were examined for the presence of ASL-O by using Architect ci8200 analyzer (Abbott, USA) and IgM against SGA A-PSC by EIA. RESULTS. In group 1, 23 (46%) individuals were recognized as positive by ASL-O level, and in group 2 - 20 (39%; p>0.05); conditionally significant exceeding of normal values (more than 1.5 times) was detected in 25% of patients of each group. Increased level of antibodies against SGA A-PSC was detected in 43 (86%) patients of group 1, and in 30 (59%) of patients of group 2 (p<0.05). In group 1 exceeding of normal values of anti-A-PSC IgM was noted mostly by 1.5 +/- 0.5 times (74%). In group 2 in 43% of patients the level of anti-A-PSC IgM was above normal more than 2 times and in most cases in uncomplicated variants of disease course. In 45% of patients with severe form of soft tissue infection this parameter did not exceed normal values (p<0.05). CONCLUSION. In acute period of disease with simultaneous determination of ASL-O and IgM against A-PSC sensitivity of serologic diagnostics of SGA etiology angina and SGA infection of soft tissues was established to reach 92% and 72%, respectively, and humoral immune response to cellular AG in each form of SGA has its features.

[Clinical efficacy of immunostimulating drugs in treatment of purulent infections].

81 patients with the acute soft tissue purulent infections were divided in 4 groups and treated with the use of traditional means without immunostimulating drugs; with immunoglobulins; with derinate and combination of both, respectively. The last treatment modality demonstrated maximal clinical efficacy. That is the decrease of the wound contamination period and inflammatory process; acceleration of granulation and epithelization. Clinical recovery was accompanied by marked positive changes of cell and humoral immune status.

Are Vitamin D Levels Associated With Risk of Deep Neck Infection?

Deep neck infection (DNI) refers to infections in spaces created by superficial and deep cervical fascia around the muscles and organs in the neck. Vitamin D is highly important for an effective immune system. Vitamin D receptors (VDR) have been identified in immune system cells, and particularly in T and B lymphocytes, macrophages, and dendritic cells. Vitamin D deficiency is thought to result in impaired immune response, decreased leukocyte chemotaxis, and an increased disposition to infection. The purpose of this study was to investigate whether vitamin D deficiency is an underlying occult factor in the development of DNI. Sixty-five patients aged 6 to 90, diagnosed with DNI, and 70 healthy age- and sex-compatible cases were included in the study. Serum levels of calcium, phosphorus, parathyroid hormone, and 25-hydroxy vitamin D (25(OH)D) were determined in each case. 25-hydroxy vitamin D levels above 20 ng/mL were regarded as normal, 12 to 20 ng/mL as insufficient, 5 to 12 ng/mL as deficient, and less than 5 ng/mL as severely deficient. Mean serum 25(OH)D levels were 10.4 (6.2) ng/mL in the patient group and 15.5 (6.4) ng/mL in the control group (P < .01). This difference was statistically significant (P < .01). Vitamin D was within normal limits in 9.2% (n = 6) of cases in the study group, insufficient in 29.2% (n = 19), deficient in 35.3% (n = 23), and severely deficient in 26.2% (n = 17). The equivalent values in the control group were 21.4% (n = 15), 48.5% (n = 34), 30% (n = 21), and 0% (n = 0). Serum 25(OH)D levels were significantly lower in patients with DNI compared to the healthy cases; 25(OH)D levels may be a factor in the development of DNI.

Skin and Soft Tissue Infections in Non-Human Immunodeficiency Virus Immunocompromised Hosts.

Skin and soft tissue infections among the non-human immunodeficiency virus infected immunosuppressed population are a serious and growing concern. Many pathogens can cause cutaneous infections in these patients owing to the highly varied and profound immune deficits. Although patients can be infected by typical organisms, the diversity and antimicrobial-resistant nature of the organisms causing these infections result in significant morbidity and mortality. The diagnostic approach to these infections in immunocompromised hosts can differ dramatically depending on the potential causative organisms. An understanding of new immunosuppressive treatments and evolving antimicrobial resistance patterns are required to optimally manage these difficult cases.

High levels of antibody to panton-valentine leukocidin are not associated with resistance to Staphylococcus aureus-associated skin and soft-tissue infection.

BACKGROUND: Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) expressing Panton-Valentine leukocidin (PVL) causes severe skin and soft-tissue infection (SSTI), necrotizing pneumonia, and other invasive infections. The PVL toxin has been implicated as a virulence factor, and antibody to a component of this toxin is under investigation as a vaccine candidate. The role of PVL in pathogenesis remains controversial, and it is unknown whether human serum antibody to PVL modulates infection. METHODS: We determined antibody levels to PVL in serum samples from children aged 0-18 years presenting with polymerase chain reaction-confirmed, PVL-positive MRSA-associated SSTI (with or without prior MRSA infection or SSTI), PVL-positive MRSA invasive infection, and PVL-negative MRSA infection, as well as uninfected control subjects. We also measured antibody-mediated neutralization of PVL-induced lysis of human polymorphonuclear cells. RESULTS: Antibody to PVL was present in healthy children reaching adult levels by 4-6 years, with a nadir at 3-11 months likely due to loss of maternal antibody. Children with a primary PVL-positive MRSA infection had moderate levels of antibody to PVL that increased after infection. Children with prior MRSA infection or SSTI had high levels of antibody to PVL after the onset of PVL-positive MRSA infection. There was no increase in antibody to PVL in this population's serum samples after the onset of infection. Serum samples from children with PVL-positive MRSA-associated SSTIs, particularly those with prior MRSA infection or SSTI, and convalescent-phase serum samples from children with invasive PVL-positive MRSA infection potently inhibited PVL-induced lysis of polymorphonuclear cells. CONCLUSIONS: Neutralizing antibody to PVL does not protect children against primary or recurrent CA-MRSA-associated SSTI.

[Intraabdominal infection in inmunodepressed patients]. / La infección intraabdominal en el paciente inmunodeprimido.

Diseases of the gastrointestinal system frequently complicate immunosuppressed patients. Endogenous flora is the principal source of infection in humans, especially in patients with dysfunction of the digestive epithelial barrier due to various factors. Bacterial translocation, traumatisms, ischemia and surgery are frequent events in the general population. In addition, important risk factors for abdominal infections in specific patients include tumoral infiltration, mucositis complicating chemotherapy and/or radiotherapy, hypoproteinemia, neutropenia and lymphocyte deficiency. Clinical pictures vary according to patients' baseline condition and the environmental setting, including nosocomial infections. The differential clinical characteristics of abdominal infections observed in distinct types of immunosuppressed patients are reviewed.

Complement Activation Is Associated With Mortality in Patients With Necrotizing Soft-Tissue Infections-A Prospective Observational Study.

Aim: We assessed whether different complement factors and complement activation products were associated with poor outcome in patients with necrotizing soft-tissue infection (NSTI). Methods: We conducted a prospective, observational study in an intensive care unit where treatment of NSTI is centralized at a national level. In 135 NSTI patients and 65 control patients, admission levels of MASP-1, MASP-2, MASP-3, C4, C3, complement activation products C4c, C3bc, and terminal complement complex (TCC) were assessed. Results: The 90-day mortality was 23%. In a Cox regression model adjusted for sex, and SAPS II, a higher than median MASP-1 (HR 0.378, CI 95% [0.164-0.872], p = 0.0226) and C4 (HR 0.162, 95% CI [0.060-0.438], p = 0.0003), C4c/C4 ratio (HR 2.290 95% CI [1.078-4.867], p = 0.0312), C3bc (HR 2.664 95% CI [1.195-5.938], p = 0.0166), and C3bc/C3 ratio (HR 4.041 95% CI [1.673-9.758], p = 0.0019) were associated with 90-day mortality, while MASP-2, C4c, C3, and TCC were not. C4 had the highest ROC-AUC (0.748, [95% CI 0.649-0.847]), which was comparable to the AUC for SOFA score (0.753, [95% CI 0.649-0.857]), and SAPS II (0.862 [95% CI 0.795-0.929]). Conclusion: In adjusted analyses, high admission levels of the C4c/C4 ratio, C3bc, and the C3bc/C3 ratio were significantly associated with a higher risk of death after 90 days while high admission levels of MASP-1 and C4 were associated with lower risk. In this cohort, these variables are better predictors of mortality in NSTI than C-reactive protein and Procalcitonin. C4's ability to predict mortality was comparable to the well-established scoring systems SAPS score II and SOFA on day 1.

Periocular necrotizing soft tissue infection in Greater Copenhagen.

PURPOSE: Necrotizing soft tissue infection, also known as necrotizing fasciitis (NF), is a fast-spreading life-threatening infection that most commonly affects the lower limbs, groin, or abdomen. Periocular necrotizing fasciitis (PNF) is rare. Limited data exist on PNF immune cell subset; hence, this study aims to determine the representation of immune cell subsets in patients diagnosed with PNF using immunohistochemical stainings. METHODS: All patients diagnosed with PNF at Copenhagen University Hospital from 2008 to 2018 were included. Their electronic medical records and pathology reports were assessed, and available tissue specimens were reviewed and stained with monoclonal antibodies for CD1a+ Langerhans' cells, CD3+ T lymphocytes, CD15+ granulocytes, CD44+ lymphohematopoietic cells, CD68+ histiocytes, CD79α+ B lymphocytes, and FXIIIa+ dendritic macrophages and Langerhans' cells. The number of positive cells was counted, and an average score was calculated. The location of immune cells and bacteria was assessed. RESULTS: The specimens were characterized by acute inflammation and necrosis of the fascia, while striated muscle involvement was less frequent. Haemolytic group A streptococci and Staphylococcus aureus were identified and mainly located in the deep dermis and subcutis in close relation to the fascia. Only few areas harboured both bacteria and inflammatory cells. Granulocytes, histiocytes and CD44+ lymphohematopoietic cells were demonstrated to be abundant in all patients, while B and T lymphocytes, dendritic macrophages and Langerhans' cells were less frequent. CONCLUSION: The immune cell subsets found in this study of PNF were consistent with those identified in the literature on NF in other anatomical locations. This study concludes that immune cells are abundant and exhibit a typical pattern in PNF.

A 72-Year-Old Man With a Violaceous Rash and Sepsis.

CASE PRESENTATION: A 72-year-old man presented to our ED less than 24 hours following the acute onset of nausea, vomiting, and diarrhea. Within 12 hours of symptom onset, he noted bilateral lower extremity pain and swelling. His pain was associated with a new violaceous irregular rash on the anterior aspect of both feet and legs. There was no history of inciting trauma or recent wounds. In addition, there was no history of consumption of raw or undercooked food (including seafood) or recent change in food source. There was accompanying fever and chills for the same duration and painful swelling of his left thumb. His comorbidities included stage IIIb classical Hodgkin lymphoma diagnosed 4 months prior. His last dose of doxorubicin, bleomycin, vinblastine, and dacarbazine chemotherapy was 4 days before presentation. He had previously failed anti-CD30 monoclonal therapy resulting from attributed pancolitis.

Infections and diabetes: Risks and mitigation with reference to India.

BACKGROUND AND AIMS: The link between diabetes and increased risk of infectious disease has long been recognized, but has re-entered sharp focus following the COVID-19 pandemic. METHODS: A literature search was conducted in PubMed for articles in English on diabetes and infection. RESULTS: Diabetes predisposes to infections through alterations in innate and acquired immune defenses. Outcomes of infection are worse in people with uncontrolled diabetes, and infection can worsen hyperglycemia in hitherto well controlled diabetes (bidirectional relationship). Diabetes does not increase the risk of infection with COVID-19 per se, but predisposes to severe disease and poor outcomes. COVID-19 has also been linked to deterioration of glycemic control as well as new-onset diabetes. CONCLUSIONS: Clinicians caring for people with diabetes should be aware of the increased risk of infections in this population, as well as the possibility of worsening hyperglycemia. A holistic approach with frequent monitoring of blood glucose levels and appropriate titration of medications, along with close attention to nutritional status, is essential to ensure the best possible outcomes.