Current challenges in acute bacterial skin infection management.

PURPOSE OF REVIEW: There are aspects of skin and soft tissue infections (SSTIs) that remain unresolved, such as current numbers, classification criteria, how best to define severity and predict the outcome, what diagnostic tests to perform, what new treatment options are available, or what the duration of antibiotic treatment should be. We have reviewed the literature over the last 18 months to clarify these issues and provide our opinion. RECENT FINDINGS: SSTIs are common and among the top 10 most frequent infections worldwide. They represent a burden on the healthcare system and have a major impact on the quality of life of patients. Regarding classification, the Infectious Diseases Society of America (IDSA) provides a practical guide that distinguishes between uncomplicated and complicated infections, acute and chronic wound infections, and necrotising and nonnecrotizing infections based on skin extension and tissue necrosis. With new microbiological and imaging diagnostic techniques, SSTIs can now be better diagnosed. New PCR techniques are available, and mass spectrometry can be applied to samples collected in liquid transport media. Moreover, new treatment methods such as photodynamic therapy, reactive oxygen, and phages are emerging. SSTI patients can be treated with shorter antibiotic courses if they receive an active drug with good tissue penetration. Antibiotic treatment in necrotizing infections can be shortened to 48 h after the last debridement. SUMMARY: SSTIs remain a challenge regarding rapid and accurate diagnosis and clinical management.

Identifying patients with difficult-to-treat acute bacterial skin infections.

PURPOSE OF REVIEW: The early recognition of acute bacterial skin infections (ABSIs) and their swift and adequate care are the major determinants of success. The features that can hamper or delay surgical and medical management can lead to 'difficult-to-treat' ABSIs. RECENT FINDINGS: Delayed diagnosis and belated management are the key obstacles to be overcome. Clinicians should be careful about underestimating the severity of ABSIs and overlooking comorbidities, especially immunosuppression. Many conditions can lead to delayed source control, including a misdiagnosis, interhospital transfers, delayed re-exploration, or extensive injuries. Difficult therapeutic issues can occur, including rapidly destructive infections from highly pathogenic microorganisms (Group-A-streptococci, Vibrio spp., Clostridium spp. and Staphylococcus aureus ) or inadequate antibiotic therapy resulting from multidrug-resistant bacteria. Impaired pharmacokinetic capacities of antibiotic agents should also be considered as a source of clinical failure due to insufficient antimicrobial activity at the site of infection. SUMMARY: Microbiological samples should be used for guiding antimicrobial therapy. Risk factors for multidrug-resistant bacteria should be considered, including local epidemiology and comorbidities. The optimization of antibiotic therapy should be achieved. Optimized care should be achieved through multidisciplinary management involving professionals with sufficient and appropriate training.

Stenotrophomonas maltophilia skin infection in an immunocompetent patient: Primary cutaneous CD30+ T-cell lymphoproliferative disorder or pseudolymphoma?

Cutaneous pseudolymphomas are a wide group of diseases mimicking cutaneous lymphoma. They comprise several skin conditions with different etiopathogenesis, clinical-pathological features, and prognosis, which may occur in the absence of an identifiable trigger factor or after administration of medications or vaccinations, tattoos, infections, or arthropod bites. They present with different manifestations: from solitary to regionally clustered lesions, up to generalized distribution and, in rare cases, erythroderma. They persist variably, from weeks to years, and resolve spontaneously or after antibiotics, but may recur in some cases. CD30+ T-cell pseudolymphomas are characterized by the presence of large, activated lymphoid cells, generally in response to viral infections, arthropod assault reactions, and drug eruptions. Stenotrophomonas maltophilia is a ubiquitous Gram-negative bacillus responsible for opportunistic infections in immunocompromised patients. Infection of intact skin in immunocompetent patients is particularly rare. Here, we report a case of a man presenting an isolated nodule histopathologically mimicking a primary cutaneous CD30+ T-cell lymphoproliferative disorder.

A Rare Case Report of Skin Infection Caused by Nocardia brasiliensis in an HIV Patient.

BACKGROUND: In October 2023, our hospital confirmed a case of a patient with HIV with concurrent infection with Nocardia brasiliensis. A patient with HIV developed a lump on the surface of the dorsum of his left hand without any obvious cause. He used a nail clipper to trim it. Due to improper disinfection and treatment methods, the condition worsened, and he subsequently sought medical attention at our hospital. A series of clinical laboratory tests were conducted based on the patient's medical history, symptoms, and signs. Based on the test results, a reasonable clinical treatment plan was adopted, ultimately achieving satisfactory treatment outcomes for the patient. METHODS: Clinical implementation of pus bacterial culture and identification (matrix-assisted laser desorption/ ionization time-of-flight mass spectrometry, MALDI-TOF MS), serum anti HIV detection, and Treponema pallidum antibody detection. Additional related auxiliary examinations: blood routine, liver function, kidney function, CRP, electrolytes. RESULTS: Blood routine and CRP (venous blood): White blood cell count 16.00 x 109/L, total number of lymphocytes 3.73 x 109/L, total monocyte count 1.66 x 109/L, total number of neutrophils 10.37 x 109/L, total number of basophils 0.10 x 109/L, average platelet volume 8.8 fL, whole blood high-sensitivity C-reactive protein 46.44 mg/L, urine routine: protein+-. Liver function test: Albumin 37.7 g/L, aspartate aminotransferase 55.5 U/L, alanine aminotransferase 63.7 U/L, blood lipid test: triglycerides 2.22 mmol/L, high-density lipoprotein cholesterol 0.77 mmol/L, coagulation function test: fibrinogen test 5.69 g/L, lymphocyte subgroup analysis: T4/T8 cell ratio 0.78, total mature T cell count 2.501 x 109/L, T8 cell count 1.351 x 109/L, B cell count 0.574 x 109/L. Serum pathogen test: anti HIV positive, Treponema pallidum antibody 214.70 IU/mL, unheated serum reactive hormone test positive (1:8). Gram staining of pus: a large number of Gram positive bacteria were found, arrange in a branching form, weak acid-fast staining: positive, pus culture and bacteria identified (MALDI-TOF MS): Nocardia brasiliensis. Clinical treatment includes trimethoprim/sulfamethoxazole 800 mg/160 mg po q12 hours, local wet compress with Baiduobang ointment, and abscess incised and drained. Seven days later, the patient had a circular ulcer on the left back without any new pustules. Slightly elevated skin temperature, no tenderness, and no purulent or bloody secretions. His condition had improved and he was discharged. Follow up infectious disease specialist hospitals treat HIV, syphilis, and other related diseases. CONCLUSIONS: Patients with HIV are prone to various types of infections, even rare bacteria, as their immune function decreases. At present, there are few reports about a patient with HIV with concurrent infection with Nocardia brasiliensis. This case can provide reference for clinical diagnosis and treatment of related diseases in the future. In addition, with the popularity of new identification methods such as mass spectrometry, laboratories should pay attention to traditional staining methods and use microscopes to detect pathogens.

Three Cases of Non-Tuberculosis Mycobacterium Skin Infection Outbreak in Beauty Institutions.

BACKGROUND: From June 2021 to July 2021, our hospital confirmed 3 cases of Mycobacterium infection in skin abscesses. All 3 patients underwent thread embedding and weight loss surgery at the same informal beauty institution, with a history of silk protein injection. None of the patients had any other underlying diseases or surgical history. Symptoms and signs show that the disease is acute and the course of the disease is short. All patients have found subcutaneous masses in different parts of the body. In most cases, the masses show redness and swelling, and some of the masses are accompanied by tenderness, wave sensation, and rupture. After some of the masses rupture, purulent secretions can be seen. METHODS: The pus secreted by the skin lesions of the three patients were cultured to a single bacterium, which was identified by MALDI-TOF MS. Multiple locus sequence typing (MLST) was performed using three specific genes (hsp65, rpoB, and secA1) and seven housekeeping genes (argH, cya, glpK, gnd, murC, pta, and purH). The results were queried through the MLST database of Mycobacterium abscess. RESULTS: All three strains of bacteria were Mycobacterium abscess type ST279 massiliense subtype. Three antibacterial drugs including cefmetazole, amikacin, and clarithromycin were administered in combination with 5-aminolevulinic acid photodynamic therapy (ALA-PDT). After 3 - 6 months, there was no obvious redness or swelling in the surrounding tissues of the wound, and no obvious purulent secretions were observed. All patients were cured and discharged from the hospital. After a follow-up of six months, there was no recurrence of the lesions. CONCLUSIONS: Medical institutions must strictly follow infection control guidelines and take preventive measures to prevent such incidents from happening again. ALA-PDT as a combination therapy for nontuberculous Mycobacterium (NTM) skin infections can improve treatment efficacy and shorten antibiotic usage time.

Cutaneous Mycobacterium avium-intracellulare infection masquerading as sarcoidosis.

Mycobacterium avium-intracellulare (MAC) infection may have different skin manifestations, including cutaneous granulomas. Granulomatous skin reactions have distinct morphologic and histopathologic appearances. We present the case of an adolescent male with cutaneous MAC, misdiagnosed as sarcoidosis after initial biopsy results, demonstrated preservation of reticulin fibers and absence of organisms within granulomas. Sarcoidal granulomas often stain positive for reticulin fibers, which could be used to distinguish them from the infectious kind. This case should alert clinicians to the fact that the presence or quantity of intact reticular fibers may not be a reliable tool to differentiate between a sarcoidal and an infectious granuloma. Our case also highlights the diagnostic challenge of cutaneous MAC infection.

Diagnosis of cutaneous primary nocardiosis in patients with normal immune function by metagenomic next-generation sequencing.

Nocardia primarily affects immunocompromised individuals, and Infection with Nocardia is uncommon and primary cutaneous nocardiosis caused by percutaneous inoculation is even rarer. Primary cutaneous nocardiosis remains a diagnostic challenge and should be considered in the differential diagnosis for any superficial cutaneous infection that arises in patients with normal immune function. We report a case that was diagnosed with primary cutaneous Nocardia by metagenomic next-generation sequencing technology.

[Skin disease caused by Mycobacterium marinum:a case report].

Mycobacterium marinum infection often affects the extremities, causing single or multiple skin lesions. With the improvement of molecular detection technology and the clinical application of NGS pathogen detection, the diagnosis rate of Mycobacterium marinum skin disease is gradually increasing. This article reported the case of a 54-year-old man who was stung by a marine fish and gradually developed swelling and nodules on his right hand and right upper limb. He was diagnosed with Mycobacterium marinum infection by detection of the tuberculosis resistance gene dissolution curve of the pus and the identification of the bacteria. Oral rifampicin combined with clarithromycin and minocycline was given for anti-infection treatment. During follow-up, the abscesses and nodules gradually shrank and eventually disappeared. By presenting the diagnosis and treatment of this case, the understanding of this disease among clinicians can be improved to avoid misdiagnosis and missed diagnosis.

Pitted keratolysis.

Pitted keratolysis (PK) is a common superficial bacterial skin infection confined to the stratum corneum. It is clinically characterized by multifocal, discrete, pits or crater-like punched-out lesions, commonly over the pressure-bearing aspects of the foot. It is asymptomatic and associated with malodour. The surface is often moist and macerated. The diagnosis of PK is often clinical and diagnostic procedures are usually unnecessary. Lifestyle modifications form the cornerstone of the management of PK. It responds well to topical antimicrobials.

Multippel erythema migrans, borrelialymfocytom og nevroborreliose hos eit barn.

BACKGROUND: Lyme disease after a tick bite often presents as erythema migrans, yet less frequent variants of this disease, such as Borrelia lymphocytoma, multiple erythema migrans and neuroborreliosis, are also seen occasionally. CASE PRESENTATION: We report a case of a tick-bitten child who first presented with an indistinct macular erythema around the left eye and a more distinct macular erythema on and around the left ear. The next day, she developed a facial palsy. INTERPRETATION: The case was interpreted as facial multiple erythema migrans and Borrelia lymphocytoma on the ear, followed by neuroborreliosis. The diagnosis of lymphocytoma was made from clinical findings and PCR of skin biopsy. She recovered quickly after intravenous ceftriaxone and is now healthy.

An octopus gift: Mycobacterium marinum multiple skin lesions.

Mycobacterium marinum is a nontuberculous mycobacterium responsible of infections in humans, ranging from skin infection to disseminated infection in immunocompromised hosts. Clinical suspicion and prompt diagnosis are crucial to prescribe appropriate antimycobacterial treatment and avoid sequelae.

Diagnosis of Lyme Borreliosis With a Novel, Seminested Real-Time Polymerase Chain Reaction Targeting the 5S-23S Intergenic Spacer Region: Clinical Features, Histopathology, and Immunophenotype in 44 Patients.

ABSTRACT: Lyme borreliosis (LB) is the most common tick-borne infection in Europe and North America. Polymerase chain reaction (PCR) is an important tool to confirm the diagnosis, but not always successful, especially when organisms are sparse. We developed a novel, seminested real-time PCR assay [target: 5S-23S intergenic spacer region (IGS)] and compared it with 3 well-established conventional PCR assays (IGS/OspA/real-time IGS) on 596 formalin-fixed, paraffin-embedded routine skin biopsies. The seminested real-time assay identified 46 cases of borreliosis while 25, 27, and 38 were identified by the 3 other assays, respectively (P 0.01, P 0.02, and P 0.42; significance P < 0.05). Clinicopathologic and immunophenotypic analysis of PCR-positive cases revealed 38 erythema migrans (EM), 6 Borrelia lymphocytomas, and 2 acrodermatitis chronica atrophicans (ACA). In the 44 PCR-confirmed cases, plasma cells were present in only a third of EM cases. By contrast, CD123-positive plasmacytoid dendritic cells were common (74%) and therefore are unlikely to be helpful in the differential diagnosis between EM and tumid lupus erythematosus. A loss of CD34 in a third of all LB specimens limits its diagnostic value in the differential diagnosis with morphea. Interstitial macrophages were common in cutaneous LB (42/43) forming interstitial granulomas in a third of all cases, and 3/38 EM, 3/6 Borrelia lymphocytomas, and 1/2 ACA were only identified by the new seminested real-time assay, suggesting that it is especially helpful in confirming the diagnosis of Borrelia lymphocytoma.

Cutaneous Actinomycosis of the Perineum in an Immunocompetent Man.

ABSTRACT: We present a case of primary cutaneous actinomycosis of unclear pathogenesis. A 30-year-old-man with no significant medical or surgical history presented to the emergency department with a 2-week history of a tender perineal mass. The patient denied trauma or perforating injury to the area. Examination of the area revealed an indurated, nonfluctuant, erythematous papulonodule located 2 cm from the anus. The lesion was unresponsive to oral and topical antibiotics and was therefore excised. The excision specimen revealed a dense mixed infiltrate partially filling the reticular dermis and extending into the subcutaneous fat. The infiltrate surrounded grains of basophilic material with an outer rim of eosinophilic radiating Splendore-Hoeppli material. Within the grains, filamentous bacteria were highlighted with Periodic acid-Schiff and Grocott's methenamine silver. The organisms were gram-positive and acid-fast negative. Given the clinical and histopathologic findings, actinomycosis was diagnosed. Two weeks later, the patient reported resolution of symptoms. The patient was lost to follow-up. This case highlights an unusual presentation of actinomycosis and the crucial role histopathology plays in diagnosis.

[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).

Diagnosis and therapy of Mycobacterium marinum: a single-center 21-year retrospective analysis.

BACKGROUND AND OBJECTIVES: In Europe, infections with Mycobacterium (M.) marinum are rare. We conducted a retrospective single-center study to assess the clinical spectrum of M. marinum infection and its diagnosis, treatment and outcome under real-world conditions. PATIENTS AND METHODS: Eighteen patients presenting with M. marinum infections between 1998 and 2018 were identified in the data warehouse of the University Hospital Würzburg and considered for detailed analysis. RESULTS: Twelve patients reported aquatic exposure. In 16/18 cases the upper extremities were affected. No invasive infections were detected. Mean time to diagnosis was 15 weeks. Histology revealed granulomatous inflammation in 14 patients while mycobacterial cultures were positive for M. marinum in 16 cases. Most patients received antibiotic monotherapy (14/18) while combination therapy was administered in four cases. Treatment (with a median duration of 10 weeks) was successful in 13 patients. Five patients were lost to follow-up. CONCLUSIONS: Our retrospective analysis of M. marinum infections at a German tertiary referral center revealed a considerable diagnostic delay and the relevance of microbiological culture, PCR and histology for diagnosis. Monotherapy with clarithromycin (rather than doxycycline) appeared as a reasonable treatment option while immunosuppressed or -compromised patients and those with extended disease received combination therapy.

Erythema Nodosum following Nocardia Infection: A Case Report.

Cutaneous nocardiosis is a rare bacterial infection that can result in various dermatologic manifestations such as actinomycetoma, lymphocutaneous infection, superficial skin infection, and secondary infection due to hematogenous dissemination. We report on a Chinese patient with erythema nodosum-like exanthema, possibly secondary to nocardiosis. Our diagnosis for this patient was based on the clinical presentation, histopathological evidence, and microbiological findings. Given the protean manifestation of Nocardia, persistent reports on new presentations of the disease are important for early identification and treatment.

Primary Lymphocutaneous Nocardia brasiliensis in an Immunocompetent Host: Case Report and Literature Review.

Nocardia spp. is a Gram-positive, partially acid-fast aerobic bacterium usually associated with infection in immunocompromised people. The most common sites of infection are the skin, lungs, and the brain, however disease can disseminate and affect every organ. Clinical manifestations of cutaneous disease are varied and frequently misdiagnosed. We present a case of an immunocompetent 66-year-old man who sustained a left finger injury while gardening. He was misdiagnosed on several occasions and treated with inappropriate antibiotics against Streptococcus spp. and Staphylococcus spp. When infection spread cutaneously, sporotrichoid (lymphocutaneous) nocardiosis was suspected and the patient was started on appropriate therapy with Bactrim which resulted in a cure. We also summarize the literature on lymphocutaneous infection by Nocardia brasiliensis. By reporting this case, we want to raise awareness among clinicians about unusual causes of cellulitis, the differential diagnosis of lymphocutaneous infection and the importance of obtaining a detailed exposure history to assist in the prompt diagnosis of nocardiosis.

An abdominal skin lesion: to lump or split? a case presentation.

Syphilis has many atypical morphologies which can present a diagnostic challenge, especially in patients with HIV/AIDS who may have multiple concurrent conditions. We describe a 41-year-old man with recently diagnosed HIV who was admitted for acute right vision loss and a diffuse rash with involvement of the palms and soles. He received diagnoses of secondary syphilis and Kaposi sarcoma in the setting of AIDS. Examination revealed an unusual dark brown-to-purple umbilicated papule with a necrotic center on the abdomen, raising a diagnostic dilemma. Skin biopsy showed secondary syphilis, despite the concurrent diagnosis of Kaposi sarcoma. The patient was treated with antibiotic and antiretroviral therapy and symptoms resolved. This case aims to share the clinical reasoning behind diagnosing a patient with HIV/AIDS with multiple concurrent conditions and to raise awareness of the many atypical cutaneous manifestations of secondary syphilis.

[Sporotrichoid nocardiosis by Nocardia brasiliensis]. / Nocardiosis esporotricoide por Nocardia brasiliensis.

Nocardia brasiliensis is a gram-positive, branched, aerobic, acid-resistant, rod-shaped bacillus that inhabits in soil, rotten organic matter and waters. Cutaneous nocardiosis in immunocompetent individuals can manifest in three different forms: actinomycetoma, superficial skin infection or lymphocutaneous infection. A case of an 85-year-old woman with an ulcerated lesion on the back of her left hand with erythematous papules in the lymphatic tract infected by N. brasiliensis is described. The microorganism was presumptively identified by conventional and inexpensive methods for a medium complexity laboratory at the species level. The morphological characteristics of colonies, the mold smell, a positive Kinyoun stain and the presence of aerial mycelium were the key tests to identify the genus. Species level identification was confirmed by mass spectrometry (MALDI-TOF MS). The trimethoprim-sulfamethoxazole treatment was effective as this agent was active in the susceptibility testing.

Efficacy and safety of ceftolozane/tazobactam as therapeutic option for complicated skin and soft tissue infections by MDR/XDR Pseudomonas aeruginosa in patients with impaired renal function: a case series from a single-center experience.

INTRODUCTION: Pseudomonas aeruginosa (PA) is a known cause of skin and soft tissue infections (SSTIs). Therapeutic options against multidrug-resistant (MDR) and extensively drug-resistant (XDR) strains of PA are limited, especially in patients with impaired renal function. Ceftolozane/tazobactam (C/T) is a novel beta-lactam/beta-lactamase inhibitor with powerful anti-PA activity. Thanks to its characteristics, it appears to be the best available anti-pseudomonal drug in many clinical scenarios. A case series of four adult patients followed between January 2018 and May 2019 is reported. All subjects presented complicated SSTIs by MDR- or XDR-PA and were affected by chronic kidney disease. RESULTS: C/T was used as a monotherapy in three cases and in combination regimen in the remaining case. In two cases, C/T was the first-line option, in the remaining ones was the salvage treatment. All patients were successfully treated without worsening of renal function and without any other adverse events. CONCLUSIONS: C/T may represent a useful option against MDR- and XDR-PA strains responsible of complicated SSTIs in patients affected by impaired renal function.