Risk Factors for Infection After Minor Dermatologic Procedures: A Case-Control Study.

BACKGROUND: There are limited published data regarding the incidence and risk factors for infection after minor dermatologic procedures, such as skin biopsy, shave, and curettage. Prior studies of infection risk after dermatologic procedures have often not specified the method of preparation of local anesthetic. OBJECTIVE: To assess the incidence and risk factors for infection after minor procedures performed in a general dermatology clinic using buffered lidocaine prepared in office. MATERIALS AND METHODS: In this retrospective case-control study, the medical record was searched for cases of infection after skin biopsies, shaves, conventional excisions, and destructions performed in a general dermatology clinic over a 4-year period. Patient and procedure characteristics were compared with uninfected controls. RESULTS: Of 9,031 procedures performed during the study period, there were 34 infections (0.4%). The odds of infection for procedures on the arm and leg were 5.29 and 9.28 times higher, respectively, than those on the head/neck. There was no significant effect of age, sex, smoking, immunosuppression, diabetes, or anticoagulation. CONCLUSION: The incidence of infection is low after minor dermatologic procedures performed with local anesthesia using buffered lidocaine prepared in office. There is a higher risk of infection on the arm and leg compared with the head and neck.

Myxofibrosarcoma presenting as an exophytic, multi-lobed nodule on the leg.

Myxofibrosarcoma may present as a dermal or subcutaneous nodule, often on the extremity of an elderly patient. We present a case of myxofibrosarcoma on the lower leg of a 77-year-old man, which illustrates the deeply infiltrative growth pattern of these tumors, as well as the potential for superficial biopsies to show lower grade histopathologic features than subsequent excision specimens.

Multiple mucocutaneous ulcers associated with cocaine-induced midline destructive lesions.

Cocaine-induced midline destructive lesions (CIMDL) occur in a small subset of cocaine users, who clinically present with inflammation and necrosis of facial midline structures such as the palate, nasal septum, turbinates, and sinuses. We present a patient with CIMDL occurring concomitantly with ulcers on the cheek and upper trunk. Multiple biopsy specimens from the cutaneous and mucosal lesions consistently showed a dense dermal/submucosal infiltrate of neutrophils and plasma cells, without vasculitis or thrombosis. The ulcers resolved following cessation of cocaine use.

Dermatoses associated with mites other than Sarcoptes.

Mites are arthropods of the subclass Acari (Acarina). Although Sarcoptes is the mite most commonly recognized as a cause of human skin disease in the United States, numerous other mite-associated dermatoses have been described, and merit familiarity on the part of physicians treating skin disease. This review discusses several non-scabies mites and their associated diseases, including Demodex, chiggers, Cheyletiella, bird mites, grain itch, oak leaf itch, grocer's itch, tropical rat mite, snake mite, and Psoroptes.

Differences in Salmonella Typhimurium infection and excretion among laboratory and field strains of the German cockroach suggest a genomic basis for vector competence.

The German cockroach, Blattella germanica, can be a vector of human enteric bacterial pathogens, including Salmonella enterica serovar Typhimurium (S. Typhimurium). Transmission of such pathogens by cockroaches has largely been considered a passive mechanical process, but recent studies have argued against this dogma by demonstrating bacterial proliferation within the cockroach gut and the necessity of specific bacterial genes for successful transmission in the feces, revealing unappreciated biological complexity in the vector-pathogen relationship between cockroaches and S. Typhimurium. However, the influence of naturally occurring variation among cockroach populations on pathogen infection and dissemination has not been investigated. Thus, this study aimed to examine whether distinct strains of B. germanica exhibit differences in their ability to become infected by and disseminate S. Typhimurium. We performed controlled infections of one long-term laboratory strain and three recently field-collected strains reared under identical conditions, then compared bacterial loads in the body and excreta of individual insects. Separately, we also compared rates of necrophagy, a behavior known to contribute to the horizontal spread of S. Typhimurium among cockroaches. Our data show significant differences in infection susceptibility, pathogen shedding in the excreta, and necrophagy between laboratory and field strains as well as between some field strains. These observations represent the first evidence that genomic variation among cockroach populations may influence their ability to become infected by and disseminate pathogens, providing further support for the hypothesis that German cockroaches are active biological vectors rather than passive mechanical vectors of S. Typhimurium. Additional studies are needed to identify the genomic drivers of vector competence for S. Typhimurium in B. germanica.

The Efficacy of a Pyrethroid-impregnated Mattress Liner on Multiple International Strains of Cimex lectularius (Hemiptera: Cimicidae) and Cimex hemipterus (Hemiptera: Cimicidae).

Modern bed bugs are resistant to multiple insecticide classes, particularly the pyrethroids. The efficacy of pyrethroid-impregnated mattress liners marketed for bed bug management has been variable. This study evaluated the efficacy of a permethrin-impregnated mattress liner, ActiveGuard, against 24 bed bug strains, consisting of both Cimex hemipterus (F.) and Cimex lectularius L. A 'mat assay', employing an allethrin-impregnated mat, was used to establish the pyrethroid resistance profile of all strains. Three experiments were conducted to evaluate the effect of ActiveGuard exposure on bed bug knockdown: 1) exposing the bed bugs continuously on the liner for up to 24 d, 2) holding the bed bugs on the liner for either 4 or 6 h, and 3) placing a noninsecticide treated fabric above the liner with the bed bugs held continuously on top. Our results indicated that all modern strains (collected within the last 15 years during the current resurgence) were pyrethroid-resistant, although the magnitude of resistance was highly variable between strains. In the continuous exposure study, an incomplete knockdown was recorded for most modern bed bug strains, with some having no knockdown even up to 7 d of constant exposure. In the 4 or 6 h exposure study, the level of knockdown was reduced even further, and very few bed bugs were knocked down in the double fabric study. The results of this study indicate that pyrethroid-impregnated mattress liners are not likely to be effective in the management of most modern bed bug infestations involving either C. hemipterus or C. lectularius.

Protecting Victims or Protecting the Brand? Secondary Victimization and Cruise Ship Crime.

It is now widely recognized that victims of crime in general, and victims of sexual offences in particular, commonly experience secondary victimization resulting from dismissive, poor, and sometimes retraumatizing treatment when they encounter the formal criminal justice system. However, little is known about victims' experiences when initially reporting crime outside of the formal justice system, for example crime that occurs during cruise ship holidays. The cruise industry is the fastest growing tourism sector. The total number of passengers onboard cruise ships internationally was expected to reach 30 million in 2019. There is limited reliable data about how many people experience crime onboard cruise ships, though crime victimization does occur. While victimization onboard cruise ships has received some attention, there is a dearth of evidence about when and how victims report crime, how victims are treated when they report their experience of crime to cruise ship companies, or the justice outcomes. Nor does the available data address whether victims of crime from diverse social groups are treated differently by cruise companies. Drawing on qualitative accounts produced by primary and secondary victims of crime onboard cruise ships, it is argued that as well as the known challenges that victims face, the addition of brand protection can compound cruise ship victims' experiences of secondary victimization. Secondary victimization refers to additional, or compounded harms experienced because of social or systemic responses to their experience of crime. There are three key implications of these findings: greater understanding of crime victims' experiences should be developed via refined, mandatory reporting of crime onboard cruise ships, and robust qualitative research; cruise ship staff need improved specialized training in responding to victims of crime, and legislation should be considered mandating an independent authority onboard cruise ships to receive, investigate and monitor victimization reports and responses.

Quantification of Fecal Spot Production as a Measure of Environmental Contamination Based on Common Bed Bug (Hemiptera: Cimicidae: Cimex lectularius L.) Population Size.

The presence of fecal spots has often been used to verify the existence of a bed bug (Cimex lectularius) infestation. However, no research has been conducted to determine how much fecal material that a bed bug population produces over time. In this study, the number of fecal spots that each nymphal life stage was capable of producing after a bloodmeal was quantified. Adult fecal spots were also quantified to determine if there was consistent production between feedings. During this study, it was discovered that bed bugs produced visible fecal spots and clear spots that were only visible under ultraviolet light. Therefore, three types of fecal spots were quantified: dark feces, light feces, and clear spots. Clear spots were produced in greater amounts (38.5-55.5%) than either dark spots (27.3-40.7%) or light spots (17.3-21.9%). For example, 5th instar bed bugs were thought to produce an average of 21 spots (dark and light) after a single bloodmeal. However, using the ultraviolet light, it was found that the 5th instars actually produced an average of 44.7 spots. Using the total fecal spot data collected during this study, researchers could project contamination potential for an infestation starting with a single gravid female over 30, 60, and 90 d. In addition, the amount of area covered by these spots was projected to be over 12 m2 in just 3 mo, which could greatly reduce the environmental and aesthetic quality of a home.

A Patient Develops Bullous Rash After Receiving the Second Dose of COVID-19 Vaccine.

Our knowledge about the clinical spectrum of COVID-19 has continued to evolve. The clinical features of the infection and vaccine are continuously updated. We present a case of bullous pemphigoid after receiving a second dose of the COVID-19 vaccine. This case highlights autoimmune skin findings seen in a patient after COVID-19 vaccination. A 70-year-old male presented with the chief complaint of blistering skin rash. He received his second dose of Pfizer COVID-19 vaccine two days before developing a painful pruritic maculopapular rash that started on his hands and extended proximally to his trunk. Physical exam was remarkable for tense bullae with negative Nikolsky sign. Biopsy and direct immunofluorescence lead to the diagnosis of bullous pemphigoid. The lesions improved significantly with steroids. Various cutaneous eruptions have been reported with Moderna and Pfizer COVID-19 vaccines, including the new onset of bullous pemphigoid. Based on our case, we suggest that bullous pemphigoid after COVID-19 vaccination is responsive to steroids and the prognosis is excellent. Understanding the clinical course and prognosis of bullous pemphigoid from the COVID-19 vaccine is of significant importance as we strive to keep our patients and communities safe. More data is needed to better guide recommendations, but so far looking at the example from our case, the benefits of COVID-19 vaccination seem to outweigh the risks. Therefore, patients should be advised to continue with future vaccinations.

Statistical analysis of the concordance of immunohistochemical stains with the final diagnosis in spitzoid neoplasms.

INTRODUCTION: The classification of spitzoid melanocytic tumors can be difficult, and pathologists rely on both histological features and clinical information to arrive at a diagnosis. We proposed that an immunohistochemical panel could be useful in classifying these neoplasms and designed a study to test the independent contribution of the panel to the final diagnosis. METHODS: We identified 121 cases previously signed out either as (1) Spitz nevus, (2) atypical spitzoid neoplasm, favor Spitz nevus, (3) atypical spitzoid neoplasm of uncertain malignant potential, (4) atypical spitzoid neoplasm, favor melanoma, and (5) spitzoid melanoma. The slides were reveiwed in random order by 4 pathologists. For the first review, the pathologists received only hematoxylin and eosin sections and patient age. Subsequently, the same pathologists interpreted the immunohistochemically stained slides (S-100A6, HMB-45, and MIB-1) on the same cases in randomized order without the benefit of either hematoxylin and eosin sections or patient age. The original diagnosis (based on a combination of clinical information, hematoxylin and eosin-stained sections and immunohistochemical stains) was the gold standard used for statistical analysis. The primary aim of the study was to determine the level of agreement between interpretions based on hematoxylin and eosin sections and age, the immunostains alone, and the gold standard, thus providing a measurement of the degree to which each of these elements contributes to the final diagnosis. The agreement between the gold standard and external review was also determined for those cases sent for external review. RESULTS: The generalized kappa statistic was 0.95 for both the hematoxylin and eosin-stained slides alone and the immunohistochemical stains alone, implying a high level of agreement among the 4 pathologists. The combined weighted kappa statistic for the comparison of hematoxylin and eosin sections and patient age to the gold standard was 0.49, and for the immunohistochemically stained slides to the gold standard 0.48, indicating that a diagnosis based on hematoxylin and eosin sections alone or immunostains alone show only a moderate and similar level of agreement with the gold standard diagnosis. Only the most controversial cases were sent for external review. The weighted kappa statistic estimate was 0.30 for the gold standard diagnosis on those cases and the external review. CONCLUSIONS: Spitzoid neoplasms remain a difficult area in dermatopathology and experts frequently disagree on the most challenging cases. An immunohistochemical panel contributes to the diagnosis of spitzoid tumors, and the contribution is statistically similar to that of hematoxylin and eosin sections and age. Interpretation remains subjective, as evidenced by the comparison of the gold standard and external review.

Histopathologic and Molecular Diagnosis of Melanoma.

Conventional histopathology is the primary means of melanoma diagnosis. Both architectural and cytologic features aid in discrimination of melanocytic nevi from melanoma. Communication between the clinician and pathologist regarding the history, examination, differential diagnosis, prior biopsy findings, method of sampling, and specimen orientation is critical to an accurate diagnosis. A melanoma pathology report includes multiple prognostic indicators to guide surgical and medical management. In challenging cases, immunohistochemistry and molecular diagnostics may be of benefit.

Dense lymphocytic infiltrates associated with non-melanoma skin cancer in patients with chronic lymphocytic leukemia.

Chronic lymphocytic leukemia (CLL) is a common hematologic malignancy associated with an increased risk of non-melanoma skin cancer. Basal cell carcinomas and squamous cell carcinomas in these patients may have an associated dense peritumoral leukemic infiltrate. This infiltrate can lead to the diagnosis of CLL and may also obscure tumor margins and pose a challenge in the assessment of perineural tumor spread. Immunohistochemical stains are useful in distinguishing leukemic B-cell infiltrates from tumor-reactive T-cell infiltrates. Leukemic cells of CLL are CD20+/CD23+/CD5+/CD43+/CD3-, whereas benign reactive infiltrates are composed of CD20-/CD23-/CD5+/CD43+/CD3+ T-cells. Given the paucity of symptoms in early stages of CLL, a dense lymphoid infiltrate surrounding a cutaneous neoplasm may serve as the first indication of CLL. We report a series of three cases of SCC with a coexisting infiltrate of CLL, including one with perineural involvement, one involving metastatic SCC, and one in which this histologic finding spurred the initial diagnosis of CLL.

Zoonoses of dermatologic interest.

Zoonoses are infectious diseases that can be transmitted from animals to humans. Transmission occurs directly or through vectors such as ticks, mosquitoes, or flies. The causative agents include bacteria, parasites, viruses, and fungi. Domestic pets and livestock, as well as wild animals, can be the source of disease. In this summary, we will focus on a number of dermatologically relevant examples.