Successful treatment of calciphylaxis by a multidisciplinary approach.

A 48-year-old woman performing peritoneal dialysis for end-stage renal disease presented with a painful leg ulcer. The investigation revealed an elevated parathyroid hormone level and the histological examination of the biopsy tissue from the ulcer revealed medial calcification of the arterioles, consistent with calciphylaxis. The patient developed additional ulcers in the lower limbs and treatment with antibiotics, cinacalcet, sevelamer, sodium thiosulfate, low calcium dialysate and hyperbaric oxygen therapy was instituted. The patient had a favourable outcome and after 9 months the ulcers had healed and the parathyroid hormone level reached the normal range. Calciphylaxis is a rare and life-threatening disorder associated with a mortality of 60-80%. Its pathogenesis is not fully understood hence there is no consensus in the treatment of this pathology.

Feasibility of conservative medical treatment for pyoderma gangrenosum.

Pyoderma gangrenosum (PG) is a chronic skin disease with an incidence of 3-10 per million, and it is often associated with underlying systemic disease. A case of PG of the left leg successfully treated with local debridement and advanced and compression dressings, without systemic treatment is reported. Progression and healing of the ulcer was incredibly rapid. The treatment of PG usually consists of systemic administration of corticosteroids. But wherever the administration of systemic immunosuppressive therapy is impractical, a topical treatment can be used. This type of treatment does not represent a mere palliative, but could be significant for healing, as in the case of our patient.

Effects of silver-based wound dressings on the bacterial flora in chronic leg ulcers and its susceptibility in vitro to silver.

Silver-based dressings have been used extensively in wound management in recent years, but data on their antimicrobial activity in the clinical setting are limited. In order to explore their effects on chronic leg ulcer flora, 14 ulcers were cultured after at least 3 weeks treatment with Aquacel Ag(®) or Acticoat(®). Phenotypic and genetic silver resistance were investigated in a total of 56 isolates. Silver-based dressings had a limited effect on primary wound pathogens, which were present in 79% of the cultures before, and 71% after, treatment. One silver-resistant Enterobacter cloacae strain was identified (silver nitrate minimal inhibitory concentration (MIC) > 512 mg/l, positive for silE, silS and silP). Further studies in vitro showed that inducible silver-resistance was more frequent in Enterobacteriaceae with cephalosporin-resistance and that silver nitrate had mainly a bacteriostatic effect on Staphylococcus aureus. Monitoring of silver resistance should be considered in areas where silver is used extensively.

Erythrodermic lichen planus.

Lichen planus (LP) is a relatively common papulosquamous disorder that is characterized by pruritic, polygonal papules in a characteristic distribution. We present a case of a 71-year-old man with erythroderma, who was ultimately diagnosed with severe, generalized LP. Treatment of severe LP is challenging, and there are few, robust, clinical trials in the literature to guide the selection of appropriate treatment. We discuss the treatment options for generalized LP and the evidence in support of these agents.

Fixed sporotrichosis as a cause of a chronic ulcer on the knee.

Chronic wounds are a major health care problem worldwide. Wound healing is a holistic endeavour that requires an accurate identification of the specific entities interfering with wound healing in a particular patient. We present a case of fixed sporotrichosis as the cause of a chronic ulcer in the knee. Although a culture of Sporothrix schenckii could not be obtained, a positive response to the sporotrichin skin test, a skin biopsy showed a suppurative granuloma and an adequate response to oral administration of potassium iodide confirmed the diagnosis. The identification and correction of the underlying aetiology of any chronic wound is the first and most important step to restore wound healing.

New method for bacterial load measurement during hydro-debridement of cutaneous ulcer.

AIM OF THE STUDY: Based on their experience using Versajet for debridement of chronic wounds, the Authors set up a study protocol to verify whether the hydro-surgical cleansing could offer the possibility of taking tissue specimens suitable for diagnostic microbiological evaluation. The aims of the study were the following: MAIN PURPOSE: To evaluate the efficacy of hydro-surgery in detecting the presence of microorganisms and measuring their load, as an alternative to conventional tissue sampling methods; SECONDARY PURPOSE: To set up an easier and less invasive diagnostic modality than surgical biopsy, even though likewise significant. RESULTS: The results of this study show that tissue specimen collection by hydro-aspiration using Versajet is comparable to biopsy sampling (and in some cases it can be even more reliable); moreover, it is not more time-consuming and is certainly less invasive. Compared to surgical biopsy, with such a method a greater amount of tissue may be collected; moreover, tissue specimens can be taken from a broader surface or, depending on the needs, from a more focused area on the margin or at the bottom of the wound.

Best practice in primary care pathology: review 9.

This ninth best-practice review examines two series of common primary care questions in laboratory medicine: (i) potassium abnormalities and (ii) venous leg ulcer microbiology. The review is presented in question-and-answer format, referenced for each question series. The recommendations represent a précis of guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents and evidence-based medicine reviews, supplemented by MEDLINE EMBASE searches to identify relevant primary research documents. They are not standards but form a guide to be set in the clinical context. Most are consensus rather than evidence-based. They will be updated periodically to take account of new information.

O uso do laser de ingap (670nm) na cicatrização de úlceras de perna em pacientes com anemia falciforme / InGaP (670nm) laser use in the leg ulcer healing in patients with sicklecell anemia

Tendo em vista que, as úlceras de perna da doença falciforme são de difícil cicatrização e, baseado nas repostas positivas obtidas com o uso da radiação laser de baixa intensidade em feridas cutâneas, este estudo teve como objetivo observar o efeito do laser de InGaP (670 nm, 6mW, vermelho, contínuo) na cicatrização dessas úlceras e no alívio da dor. A amostra foi constituída de seis pacientes portadores de anemia falciforme, com úlcera de perna, divididos igualmente em dois grupos: A (experimental) e B (controle). Os dois grupos seguiram o mesmo protocolo de curativo, sendo que, o grupo A, foi submetido à radiação laser de InGaP (3 J/cm2 , três vezes por semana, durante três meses). A análise estatística, comparando os dois grupos, mostrou uma diferença significativa na redução da área da úlcera do grupo experimental através do teste de Mann-Whitney (p = 0,014) e uma tendência linear decrescente (c2 = 0,52; p = 0,770761) através do teste Qui-quadrado de tendência. O teste Komogorov – Smirnov mostrou uma diferença significativa (p = 0,034) na redução da dor. Os resultados evidenciaram que o grupo experimental obteve maior redução da área da úlcera, maior formação de tecido de granulação, e maior alívio da dor.

[Skin infection with Fusarium in an immunocompetent patient]. / Infección cutánea por fusarium en paciente inmunocompetente.

Fusarium spp. are fungi found throughout the world and can cause a great variety of skin infections, mainly in immunodepressed individuals. We present a case of skin infection with Fusarium sp. which manifested as painful superficial ulcers on the legs of an immunocompetent female patient, who had applied <> as a <> for leg pain. The condition was cured with oral itraconazole and local treatments.

[Nocardia brasiliensis leg ulcer and nodular lymphangitis in France]. / Ulcère de jambe et lymphangite nodulaire à Nocardia brasiliensis en France métropolitaine.

INTRODUCTION: Nocardia brasiliensis is a very rarely reported cause of chronic phagedenic ulcerations. We report the case of an elderly woman who developed such an infection after falling on her right leg on the road in the Bresse country (an essentially agricultural and bovine-cattle breading region) and developed a chronic phagedenic ulcer secondarily complicated by nodular lymphangitis of the thigh. CASE REPORT: A 75 year-old woman fell on her right leg on the side of the main road outside her hamlet in the Bresse country and secondarily developed a chronique phagedenic ulceration. We first considered her as suffering from pyoderma gangrenosum. A complete scanning only revealed an autoimmune thyroiditis and a rapidly healing gastric ulceration, and none of the treatments, either local or systemic, helped the skin condition to heal. After 3 weeks of application of a local corticoid ointment, the patient developed fever, general malaise, an exacerbation of her wound and an infiltration of the skin round her knee, together with nodular lymphangitic dissemination. A supplementary bacterial swab disclosed massive proliferation of a slow-growing Gram-positive bacillus, which proved to be Nocardia brasiliensis, together with a methicillino-sensitive Staphylococcus aureus. The treatment with sulfamethoxazole-trimetoprim gave a rash after 12 hours and was changed to amoxicillin and clavulanic acid, which rapidly proved to be permanently effective. DISCUSSION: The revelation of this particular slow-growing bacteria is difficult and requires bacterial swabs. Nocardia brasiliensis is relatively rare in primary skin ulcerations and we discuss the reasons why an elderly women should find this bacteria on the road outside her hamlet in the French countryside. This particular infectious condition requires general scanning, to make sure that the primary skin condition does not extend to other organs. We review the therapeutical options for patients who exhibit allergic reactions to the classically effective antibiotic drugs.

[How I treat... the critical bacterial colonization of a leg ulcer. The Yin and the Yang features of silver-based dressings]. / Comment je traite.... la colonisation bactérienne critique d'un ulcère de jambe. Le Yin et le Yang des pansements argentiques.

The critical bacterial colonizaion of leg ulcers can impair their healing rate, aggravate the patient discomfort and increase the medical and nursing costs. In recent times, the dressings designed for leg ulcers have followed a pace of conceptual revolution. Some of them are now offered containing an antiseptic of the silver salt family. The silver concentraton delivered into the wound bed is important to consider when assessing treatment efficacy. The diversity of the silver-based dressings currently on the European market is as large as their differences in activity. Only a minority of these dressings adequately control the wound biocenosis. Their cost which is high for the patient, must be compared to that of nursing care that may become less important. The expected beneficit is a reduction in healing time.

A "fishy remedy": an unusual transmission of Vibrio vulnificus infection.

This case report describes a unique transmission of Vibrio vulnificus infection. A 38-year-old woman with recurrent cellulitis and chronic ulcer on her leg developed necrotizing cellulitis and sepsis caused by V. vulnificus. Meticulous history investigation revealed the link to contaminated fish blood that had been applied on the ulcer by a traditional healer. Through this case, it may be stressed that a traditional remedy can sometimes be harmful and life-threatening.

[Methicilline-sensitive and methicilline-resistant Staphylococcus aureus related morbidity in chronic wounds: a prospective study]. / Etude prospective comparative de la morbidité des Staphylococcus aureus métisensibles et métirésistants dans les plaies chroniques.

OBJECTIVE: Staphylococcus aureus is the most common bacteria responsible for cutaneous infections. Its capacity to adapt has led to the selection of methicilline-resistant strains (MRSA). These strains create specific problems in their management in dermatology (mode of contamination, treatment, added costs, increased nosocomial risks). The objective of our study was to search for morbidity of MRSA in chronic cutaneous wounds in hospital settings and assess the need of systemic antibiotic therapy. PATIENTS AND METHODS: We have conducted a one-year prospective study. All the patients hospitalized in the department with leg ulcers or foot wounds were included. Following local sampling for bacteriological examination, three groups were constituted: methicilline-sensitive patients with staphylococcus aureus (MSSA), methicilline-resistant staphylococcus aureus patients and patients in whom these bacteria were absent. Only the first two groups were compared after studying the past history, clinical description of the wound at the start of the study, results of the infectious bacteriology and of the clinical and bacteriological evolution of the wounds. RESULTS: The two groups studied were similar in number, past history, clinical aspect and therapeutic management. Only malnutrition was more frequent in patients exhibiting MRSA. There was no difference with the evolution of the wounds. CONCLUSION: Our study did not reveal any difference in the morbidity of staphylococcus aureus in the cutaneous wounds whether methicilline sensitive or resistant. Systematic antibiotherapy is not justified in the absence of signs of infection.

Topical phenytoin versus EUSOL in the treatment of non-malignant chronic leg ulcers.

OBJECTIVE: To compare topical diphenylhydantoin (phenytoin) with Edinburgh University solution of lime (EUSOL) in terms of rate of ulcer healing, analgesic and antibacterial properties in non-malignant chronic leg ulcers. DESIGN: A prospective randomized controlled study. SETTING: Muhimbili National Hospital surgical wards from August 2000 to September 2001. PATIENTS: One hundred and two patients with non-malignant chronic leg ulcers of various aetiologies, 50 in the study (phenytoin)group and 52 in the control(EUSOL) group. INTERVENTIONS: Study group studied by sprinkling phenytoin powder and the control group with EUSOL, in both groups the ulcers were addressed daily and followed up for 28 days or until they epithelialised or were ready for skin grafting. The data collected included demographic characteristics of patients, aetiology of the ulcers, pus discharge, severity of pain due to the ulcers, bacterial cultures from ulcer swabs, rate of reduction in mean ulcer surface area and outcome of treatment. RESULTS: The study enrolled 67 male and 35 female patients over a 14 month period (August to September 2001). Fifty patients formed the study group and 52 formed the controls. The age range was 12-56 years; the majority being in the 27-31 year age group. Major causes of chronic leg ulcers were those infected following trauma (27.5%), chronic non-specific inflammations (21.6%) and infected burn wounds (15.7%). At enrolment, the duration of ulcers ranged from 3-156 weeks and 3-128 weeks in the phenytoin and control groups respectively. Overall, there was significant reduction in pain(p < 0.05) on day seven in the phenytoin group. Furthermore in patients who presented with severe pain, there was a significant reduction in pain in the phenytoin group on the fourteenth day (p < 0.01). Clearance of ulcer discharge was also significant in the phenytoin group on the seventh and fourteenth day of treatment(p < 0.05). The commonest bacteria isolated were pseudomonas aeruginosa (54.9%) and staphylococcus aureus (10.8%). However, bacterial colonization clearance was not statistically significant when the two groups were compared. The rate of formation of healthy granulation tissue was highly significant in the phenytoin group by the fourteenth and twenty first days of treatment (p < 0.001). The phenytoin group showed significant reduction in the mean ulcer surface area on days 7, 14, 21 and 28 (p < 0.05). Chronic ulcers due to animal bites healed fastest followed by those due to trauma. CONCLUSION: Phenytoin powder is cheap and easily applied topically on ulcers, effectively relieves pain, clears discharge and enhances formation of granulation tissue thereby promoting healing; reducing morbidity and financial burden enabling its use in resource-poor environments.

In vitro activity of Melaleuca alternifolia (tea tree) oil against bacterial and Candida spp. isolates from clinical specimens.

This study investigates the in vitro activity of tea tree oil (TTO) against a range of wild strains of microorganisms isolated from clinical specimens of leg ulcers and pressure sores. The antimicrobial effectiveness of TTO is determined in terms of minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) or minimum fungicidal concentration (MFC). The isolates include methicillin-resistant Staphylococcus aureus (MRSA), S. aureus, faecal streptococci, beta-haemolytic streptococci, coagulase-negative staphylococci, Pseudomonas spp. and coliform bacilli. Eleven Candida spp. isolates from skin and vaginal swabs also are tested. Using an agar dilution assay, the MICs of TTO in 88 out of 90 isolates was 0.5-1.0% (v/v), whilst with P. aeruginosa it was >2% (v/v). A broth microdilution method was used to determine MIC and minimum cidal concentration (MCC) of 80 isolates. In 64 isolates, TTO produced an inhibitory and cidal effect at 3% and 4% (v/v), respectively. S. aureus and Candida spp. were the most susceptible to TTO, with MICs and MBCs of 0.5% and 1%, respectively. P. aeruginosa and the faecal streptococci isolates, with MICs and MBCs of >8%, were resistant to TTO.

Mycobacterium haemophilum infection in a Japanese patient with AIDS.

Mycobacterium haemophilum has been described as a pathogen that causes cutaneous lesions in immunocompromised patients. A specimen from a skin ulcer on the leg of a Japanese patient with acquired immunodeficiency syndrome yielded acid-fast bacilli on blood agar plates after 4 weeks of incubation at 30 degrees C, but the organism was not found on Ogawa egg slants. The organism was identified as M. haemophilum, on the basis of 16S rRNA gene sequence analysis. Prolonged culture in an optimal environment that includes an iron supplement, and growth temperatures at 28 degrees to 33 degrees C are necessary to grow M. haemophilum. Genotypic characterization of 16S rRNA is useful for a rapid diagnosis of this slowly growing mycobacterium.

Mycobacterium ulcerans infection (Buruli ulcer): first reported case in a traveler.

A chronic, painless sore developed over a 2-month period on the left calf of a Canadian man traveling for 8 months in Africa. A presumptive diagnosis of a Mycobacterium spp. infection was made despite initially negative biopsy and culture results, after failure of several courses of anti-bacterial antibiotics. Mycobacterium ulcerans was eventually isolated and the lesion progressed despite treatment with multiple anti-mycobacterial agents. The lesion finally responded to wide and repeated excision, aggressive treatment with anti-mycobacterial antibiotics, and split-thickness skin grafting. The isolation and treatment of this unusual organism are discussed.

Therapy of lower extremity infections with ciprofloxacin in patients with diabetes mellitus, peripheral vascular disease, or both.

PURPOSE: Lower extremity infections in the presence vascular insufficiency are difficult and costly to treat. Few well-controlled clinical trials evaluating the management of these infections exist. We decided to investigate the ability of a new fluoroquinolone, ciprofloxacin, to reduce the morbidity associated with these infections and the amount of in-hospital time required for the administration of antibiotic therapy. PATIENTS AND METHODS: Forty-eight patients with peripheral vascular disease (46 with diabetes mellitus) who presented to the hospital for treatment of lower extremity infections were randomized in a blinded fashion to receive oral ciprofloxacin at a dosage of either 750 mg or 1,000 mg twice daily. Patients with osteomyelitis received three months of therapy and those with infections limited to soft tissues, three weeks of ciprofloxacin treatment. All subjects were followed for one year. RESULTS: One patient received an amputation 24 hours after enrollment, and two patients discontinued therapy after 20 and 34 days because of adverse effects and were not evaluable. At the one-year follow-up, 27 of the 45 (60 percent) evaluable patients had a fully successful outcome defined as not requiring either repeat antimicrobial therapy for their initial infection or amputation of the involved extremity. In the group of 18 patients in whom therapy failed, a total of only nine amputations were required. In the 15 patients whose lesion closed during therapy, 93% (14 patients) experienced a long-term successful outcome. CONCLUSION: Treatment with this new fluoroquinolone offers promise for the improved outcome of patients with the serious infectious complication of infected lower extremity ulcerations in peripheral vascular disease, diabetes mellitus, or both.

A comparative study of ciprofloxacin and conventional therapy in the treatment of patients with chronic lower leg ulcers infected with Pseudomonas aeruginosa or other gram-negative rods.

Twenty-six elderly patients with chronic leg ulcers infected by Pseudomonas aeruginosa or other aerobic Gram-negative rods were randomised to two treatment groups. The control group (eight patients) received conventional local therapy and the other group (18 patients) was treated with oral ciprofloxacin for three months in addition to conventional local therapy. In the beginning of the study both groups were comparable with the age of the patients and the associated diseases including impairment of arterial and venous circulation in the lower legs. Also the size, duration and the severity of the inflammation reaction in the leg ulcers were comparable before the start of the therapy. Ciprofloxacin was clinically more effective than the standard therapy in reducing the size of the ulcer (p less than 0.05). Also the need of extra systemic antibiotics decreased significantly in the ciprofloxacin group compared with the controls. In three out of eighteen ciprofloxacin treated patients the leg ulcers disappeared completely during the three months' study period compared with none in the control group. However, ciprofloxacin resistant strains, mainly staphylococci, appeared in the leg ulcers in 67% of the ciprofloxacin treated patients compared with 0% in the control group (p less than 0.01). No significant side-effects due to ciprofloxacin except the resistant strains were noticed. We conclude that oral long-term ciprofloxacin therapy is effective in the treatment of chronic leg ulcer infections due to Gram-negative rods but selection of ciprofloxacin resistant strains is a problem in this patient group.