A 36-year-old man with vomiting, pain abdomen, significant weight loss, hyponatremia, and hypoglycemia.

Diagnosis of Strongyloides stercoralis hyperinfection can be a challenge. The key to a timely diagnosis is to have a high index of suspicion. We present a rare case of a 36-year-old human immunodeficiency virus negative male patient, who was on multidrug therapy for lepromatous leprosy and was treated for type 2 lepra reactions with steroids in the past. The patient presented with vomiting and pain abdomen, persistent hyponatremia, and terminal hypoglycemia. He had features of malnutrition and had a rapid downhill course following admission. A diagnosis of S. stercoralis hyperinfection with sepsis and multiorgan failure, adrenal hemorrhage, and syndrome of inappropriate antidiuretic hormone secretion was established on a postmortem examination.

Clinical and bacteriological profile and outcome of sepsis in dermatology ward in tertiary care center in New Delhi.

BACKGROUND: There is paucity of data regarding the clinical and bacteriological profile of sepsis in dermatology in-patients. AIMS: To study the frequency, etiology, and outcome of sepsis dermatology in-patients. METHODS: The study was conducted in a 30-bedded dermatology ward of a tertiary care center. Sepsis was defined by presence of ≥2 SIRS (systemic inflammatory response syndrome) criteria along with evidence of infection (clinically obvious/culture proven infection of skin or internal organs). Patients were also assessed for known (common) risk factors of sepsis. In suspected sepsis patients, at least two samples of blood cultures by venepuncture were taken. Pus, skin swab, urine, and sputum samples were also collected for culture as needed with avoidance of contamination. RESULTS: Among 860 admitted patients studied from November 2004 to July 2006, 103 (12%) fulfilled SIRS criteria. Of these, 63 had nonsepsis causes of SIRS positivity, while 40 (4.65%) had sepsis. Majority of the sepsis patient had vesicobullous diseases (42.5%), erythroderma (25%), toxic epidermal necrolysis (TEN) (22.5%). Severe sepsis developed in 17 (42.5%) patients, while 15 (37.5%) died. Methicillin-resistant Staphylococcus aureus (MRSA) was the commonest organism isolated (99; 25.9%) in all culture specimens followed by Acinetobacter spp. (52; 13.6%), Pseudomonas spp. (40; 10.5%), Methicillin-sensitive S. aureus (MSSA: 33; 8.7%), and Klebsiella spp. (22; 5.8%). Various risk factors affecting mortality and sensitivity patterns for various isolates were also analyzed. CONCLUSION: Sepsis occurred in 40 (4.65%) inpatients in dermatology ward. The frequency of sepsis was highest in TEN (90%), followed by drug-induced maculopapular rash (20.0%), erythroderma (17.5%), and vesicobullous diseases (8.5%). MRSA, acinetobacter, pseudomonas, MSSA, and Klebsiella were important etiological agents involved in sepsis in dermatology in-patients.

Septicemia com múltiplas lesöes ósseas supurativas como complicaçäo do eritema nodoso hansênico / Septicemia with suppurative bones lesions with complication of erithema nodosum leprosum

Um homem de 57 anos de idade, relata história de hanseníase com 26 anos de duraçäo e ainda em atividade. Desde a primeira consulta ao Hospital apresenta episódios de Eritema nodoso hansênico (ENH), frequentes, intensos, muitas vezes acompanhados por neurites, adenomegalia, icterícia e anemia. Desenvolveu lesöes ulcerativas de extremidades inferiores e superiores que evoluiram para infecçäo secundária, necrose e exposiçäo de planos músculo-tendinosos e ósseos. Na última internaçäo apresentou ainda episódios de ENH, mas predominou quadro clínico caracterizado por abscessos de regiöes glúteas; dores ósseas ao nível dos membros inferiores, crista ilíaca direta e tórax; dificuldade à micçäo com progressiva diminuiçäo do volume urinário; picos eventuais; melena; distensäo abdominal e nos últimos dias dificuldade respiratória. Os exames laboratoriais evidenciaram queda dos leucócitos no sangue (9.900-3.700 mm**3); osteoporose vertebral com colapso parcial dos corpos vertebrais D4, D5, D11 e sinais de osteomielite em tíbia e perônio. Na autópsia observou-se um paciente virchoviano em estado regressivo adiantado, com pequena quantidade de bacilos granulosos em troncos nervosos e linfonodo axilar. Näo se detectaram lesöes ativas de ENH em pele, nervos e vísceras, havendo apenas um foco de necrose e supuraçäo em organizaçäo em linfonodo axilar. O paciente faleceu em choque séptico decorrente de múltiplas necrotizantes e supurativas em corpos vertebrais, arcos costais e clavículas. A rotura de um abscesso costal no hemitórax direito levou à pleurite sero-fibrino-purulento, intensa. Observou-se trombose de veia axilar direita, de veia cava inferior junto à desembocadura de suprahepática, e trombose do átrio direito; colite aguda úlcero-flegmonosa e necrotizante ao nível de ceco; nódulo de Criptococose em pulmâo esquerdo, e hiperplasia nodular da próstata. Discute-se a relaçäo entre ENH e instalaçäo do quadro séptico, lembrando-se a possibilidade de infecçäo secundária nas lesöes cutâneas de ENH, de exaustäo da resistência imune frente a episódios sub-entrantes de ENH, e açäo dos corticosteróides na queda de resistência à microorganismos patógenos habituais ou oportunistas

Bacillaemia in lepra reaction: its correlation with liver pathology.

Thirty patients of lepromatous leprosy in a state of reaction (ENL) were studied for bacillaemia and a correlation was made with liver pathology. Buffy coat smears were examined in all, eliminating as far as possible the chances of contamination of blood by the skin bacilli. Thirteen out of thirty patients showed presence of acid fast bacilli (AFB) in the buffy coat smear. Hepatic involvement in the form of leprous granuloma was observed in all, of which 93.3% showed presence of AFB. It is concluded that during reaction the possibility of heightened bacillaemia is less likely and that the systemic spread of infection is not accentuated during the bouts of reaction.