Electrosurgical debulking of pretibial myxedema of the foot.

Pretibial myxedema or thyroid dermopathy constitutes dermal deposition of mucin, primarily hyaluronic acid and chondroitin sulfate. It is a manifestation of autoimmune thyroiditis, seen more in Graves disease than in Hashimoto thyroiditis. The time delay from treatment of hyperthyroidism to appearance of localized myxedema varies from one month to 16 years (mean 5.13 years). Despite a variety of therapeutic options, failure and relapse rates are high. Therapeutic options reported in the literature include compression, topical and intralesional corticosteroids, oral pentoxifylline, octreotide, rituximab, plasmapheresis, and high-dose intravenous immunoglobulin. We share our experience in two patients who were treated with electrosurgical debulking of selected longstanding myxedematous lesions, with one positive result and one negative result.

Simplified noncultured autologous cell grafting for the treatment of chronic nonhealing ulcers: the six-well plate technique.

Chronic recalcitrant ulcers are associated with severe morbidity, and there are few effective treatment options available. Living skin substitutes are an important form of adjuvant therapy to enhance healing of such wounds. We investigated a novel, simplified, noncultured, autologous, cell grafting procedure, using a six-well plate technique, to treat chronic recalcitrant wounds. This was a prospective pilot study that involved harvesting an ultrathin split-skin graft from the gluteal region, which was washed, separated and prepared in six different wells to obtain an autologous mixture of keratinocytes, melanocytes and fibroblasts; this was subsequently applied directly to the wound using a hyaluronic acid (HA) matrix. Eight patients with a total of 14 ulcers were recruited. The primary endpoint assessed was the percentage of re-epithelialization of the ulcers. Secondary endpoints included quality of life and wound bed indices. At baseline, the median wound surface area was 7.4 cm(2) (mean 17.6 ± 23.6 cm(2) , range 0.5-80.0 cm(2) ) with a median duration of 18 months (mean 70.2 ± 95.9, range 3-216 months). The median wound surface area was reduced by 74.3%, from 7.4-1.9 cm(2) , at the final visit. Overall, 28.3% of the ulcers achieved complete healing, and 71.3% of the ulcers had reduction in wound size. Post-graft, there was also improvement in secondary wound bed parameters and all quality of life domains of the Cardiff Wound Impact Schedule. These results suggest that this noncultured autologous six-well technique might be beneficial for treating recalcitrant ulcers.

Lobomycosis: diagnosis and management of relapsed and multifocal lesions.

We report a case of lobomycosis in the left leg of a patient that had traveled to the endemic Brazilian Amazon region. After surgical resection of the lesion, there was relapse with local dissemination of the disease and the treatment was successfully performed by oral itraconazole and cryosurgery.

Pneumococcal septicaemia with Purpura fulminans in an 11-month-old child.

Purpura fulminans (PF) is a syndrome characterised by acute onset of rapidly progressive haemorrhagic necrosis of the skin due to dermal vascular thrombosis, mainly occurring during meningococcal sepsis. It occurs rarely in the course of infection with Streptococcus pneumoniae and most cases report Meningococcus as the causing agent. This is a case report of successful conservative limb-preserving management of PF and sepsis caused by Streptococcus pneumoniae in an 11-month-old girl.

Bacteraemic necrotizing fasciitis with compartment syndrome caused by non-O1 Vibrio cholerae.

Non-O1 Vibrio cholerae are gram-negative rods that can cause sporadic gastroenteritis, bacteraemia, and extraintestinal infections, primarily following the consumption of raw seafood or exposure of damaged skin to contaminated saltwater during the summer months. Bacteraemic necrotizing fasciitis caused by non-O1 V. cholerae has rarely been reported. Liver cirrhosis, haemochromatosis, and immunosuppression are important factors contributing to the severity of the infections and outcome. This report describes a case of liver cirrhosis in which right lower leg compartment syndrome and acute renal failure presented as the initial symptoms of bacteraemic necrotizing fasciitis. The organisms growing in the wound and blood cultures were identified as non-O1 V. cholerae. After antibiotic therapy, fasciotomy, right above-knee amputation, repeat debridement of the left lower leg and split-thickness skin grafts, the patient was eventually discharged in a stable condition.

[Cutaneous calciphylaxis treated by autologous keratinocytes graft and subtotal parathyroidectomy]. / Nécrose cutanée par calciphylaxie traitée par greffe de kératinocytes autologues et parathyroïdectomie partielle.

BACKGROUND: Cutaneous calciphylaxis, seen most often in dialysis patients, is characterised by skin necrosis, and is a disabling and lifethreatening disease. Despite intensive topical treatment, recourse to parathyroidectomy is often necessary. We report the case of a female patient with skin necrosis due to calciphylaxis: pain and necrotic lesions were controlled by grafting of cultured autologous keratinocytes (Epibase). CASE REPORT: A 75-year-old woman with a 5-year history of dialysis-dependent chronic renal failure secondary to nephroangiosclerosis presented a very painful necrotic ulceration on her left leg. In spite of an autologous patch grafts, the lesions rapidly deteriorated. Laboratory data showed high levels of calcium, phosphate and parathyroid hormone and imaging suggested parathyroidal adenoma. Although cutaneous biopsy was not performed, the diagnosis of cutaneous necrosis due to calciphylaxis with tertiary hyperparathyroidism was established. Treatment consisted of a low-calcium and low-phosphorus diet with autologous keratinocytes grafts (Epibase). After the third application of keratinocytes, the pain disappeared, necrosis ceased and wound healing began. Subtotal parathyroidectomy was performed two months after the start of grafts. At three months, the patient was cured. DISCUSSION: . Calciphylaxis is an obstructive vascular disease secondary to calcification of the arterioles leading to ischemic tissue necrosis. Prompt diagnosis is essential since this disease is disabling and life-threatening due to sepsis and ischemic complications. In our case, autologous keratinocyte grafts allowed pain relief to be achieved within large expanses of cutaneous necrosis after correction of calcium and phosphorus levels, thereby allowing parathyroidectomy to be performed under optimal conditions.

Chromoblastomycosis.

A 70-year-old male agriculturist from a rural area presented with a history of a painless verrucous lesion over the medial aspect of the left leg for 1 year following abrasion by a branch of a coconut tree. KOH preparation of the skin biopsy showed evidence of fungal elements. Cladophilalospora sp. was isolated in culture. The case was diagnosed as chromoblastomycosis. As there was no response to itraconazole, complete surgical resection of the lesion was done. At follow-up after 1 year there was clinical as well as mycological cure.

Elephantiasis nostras verrucosa successfully treated by surgical debridement.

BACKGROUND: Elephantiasis nostras verrucosa represents a rare group of cutaneous changes comprising dermal fibrosis, hyperkeratotic, verrucous, and papillomatous lesions after chronic secondary, nonfilarial lymphedema. There is no standard treatment for this rare cutaneous manifestation. OBJECTIVE: This article describes debridement that is helpful when performed in addition to physiotherapy. METHODS: We present a patient who was treated by shaving the verrucous area with a blade of a freehand knife and by subsequent abrading of the mossy area using a motor-powered grinder. RESULTS: Reepithelization was completed in 2 weeks. A compression stocking was used to treat the lymphedema. Ten months after the operation, we saw no signs of disease recurrence. The result was also aesthetically satisfactory. CONCLUSIONS: Surgery in such case may not always be the best treatment because it does not treat the cause of disease but only treats the cutaneous symptoms. Nevertheless, debridement is a rapid and an aesthetically acceptable form of treatment.

[The case of a patient with multiple superinfected necrosis of both legs caused by vasculitis disease]. / Fallbericht einer Patientin mit multiplen superinfizierten Nekrosen beider Ober- und Unterschenkel auf dem Boden einer Vaskulitis.

Vasculitis can lead to skin necrosis, which typically shows decayed recovery tendency and is able to lead to local as well as systemic inflammation. By repeated necrosectomy, vacuum therapy, split skin graft transplantation as well as simultaneous immunosuppression and systemic antibiotics, the cutaneous manifestations of vasculitis where cured.