Cutaneous Leishmaniasis: Contribution of Routine Histopathology in Unexpected Encounters.

The ulcerated papules of cutaneous leishmaniasis represent an unusual form of granulomatous dermatitis caused by Leishmania species, a protozoan transmitted by sandfly bites. As the disease is not native to North America, clinical suspicion is partially based on a compatible travel history and may result in a biopsy. The key role of standard morphology is the identification of Leishmania organisms, supplemented by Giemsa and/or CD1a immunostaining. Histologically, the organism may be confused with Histoplasma species, which is resolved by staining with methenamine silver or PAS. Four cases of cutaneous leishmaniasis are presented for which organisms were present in 3; polymerase chain reaction and DNA sequencing for speciation done by the Center for Disease Control and Prevention (CDC) was confirmatory in 3 cases, including the one case without histologically identifiable organisms. Rare unexplained cases of cutaneous leishmaniasis without a travel history have been reported outside endemic areas. The present cases emphasize the importance of diagnostic awareness of unusual infections such as this in the context of political unrest, ease of international travel, climate change and the possible expansion of geographic vector distribution. In the morphologic absence of organisms, the diagnosis may require molecular techniques, currently available on a referral basis to pathologists without charge from CDC.

Antishear therapy for toxic epidermal necrolysis: an alternative treatment approach.

BACKGROUND: Toxic epidermal necrolysis syndrome is a devastating disease, with mortality rates ranging between 20 and 60 percent. This study evaluated an alternative treatment approach using antishear wound care and compared outcomes using the severity of illness score for toxic epidermal necrolysis syndrome (SCORTEN) system. METHODS: Records of 48 patients with a histopathologic diagnosis of toxic epidermal necrolysis syndrome treated with burn equivalent critical care and antishear wound care from September of 1985 to April of 2004 were reviewed. Observed mortality data were compared with those expected using the SCORTEN, and the standardized mortality ratio was calculated. RESULTS: The overall mortality rate was 27 percent. Factors affecting mortality were advancing age, time to burn unit admission, multisystem organ failure, and presence of comorbidities (p = 0.02, p = 0.02, p < 0.001, and p = 0.003, respectively). Chronic renal insufficiency and malignancy were two independent risk factors for nonsurvival (p = 0.04 and p = 0.004, respectively). Patients with a SCORTEN score of 2 or less had no mortality rate in this series. Observed and predicted mortality rates were comparable for patients with SCORTEN scores of 3 or greater. Patients with combined scores of 3 or less had a standardized mortality ratio score of 0.58 (42 percent mortality reduction). Overall, the standardized mortality ratio was 0.89 (11 percent mortality reduction). CONCLUSIONS: Transfer to a burn intensive care unit and initiation of critical care and wound protocols similar to those used for burn patients are recommended for patients with toxic epidermal necrolysis syndrome. Antishear wound care provides an effective alternative wound care approach with equivalent mortality rates.

Definitive closure of the infected median sternotomy wound: a treatment algorithm utilizing vacuum-assisted closure followed by rigid plate fixation.

Mediastinitis and sternal wound dehiscence are devastating and life-threatening complications of median sternotomy incision. Ten consecutive patients between July 2001 and May 2005 were diagnosed with sternal wound infection and dehiscence following median sternotomy. Patients were managed by precise debridement and wound excision in the operating room and then dressed with vacuum-assisted closure device. Intravenous antibiotics were prescribed for wound and blood culture microbiological sensitivity. When wounds were bacteriologically controlled, patients returned to the operating room for definitive closure using rigid sternal plating. All patients were extubated postoperatively. No patients died. Average total hospital stay was 21 days. The pectoralis advancement flap was exclusively used for soft tissue reconstruction in 7 patients. There were 2 cases of chronic superficial sternal infection requiring plate removal; however, bony union of the sternum was achieved in all patients. This treatment algorithm provides a useful management strategy for patients with complicated median sternotomy.