Cutaneous Manifestations of SARS-CoV-2 Infection.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused the coronavirus disease 2019 (COVID-19) pandemic, affecting people worldwide. SARS-CoV-2 infection is a multisystem disease with potential for detrimental effects on various systemic organs. It affects people of all ages with varying degrees of disease severity. Patients with SARS-CoV-2 infection commonly present with dry cough, fever, and fatigue. A clinical spectrum of skin findings secondary to SARS-CoV-2 has also been reported. The most common cutaneous patterns associated with COVID-19 are chilblain-like lesions (CBLL), maculopapular lesions, urticarial lesions, vesicular lesions, and livedoid lesions. Other skin findings secondary to SARS-COV-2 infection are erythema multiforme (EM)-like lesions and skin findings associated with multisystem inflammatory syndrome in children (MIS-C) and rarely multisystem inflammatory syndrome in adults (MIS-A). Physician awareness of skin manifestations of SARS-CoV-2 infection can help with early identification and treatment. This narrative review provides an update of various skin manifestations reported with SARS-CoV-2 infection, including clinical presentation, proposed pathogenesis, histopathology, prognosis, and treatment options.

Covid-19 skin manifestations: an update.

PURPOSE OF REVIEW: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or COVID-19 is a multisystemic disease manifesting mainly with dry cough, fever, and pneumonia and can present with a myriad of cutaneous manifestations. This chapter will review SARS-CoV-2 associated cutaneous findings, including incidence and relevance to the pediatric population. RECENT FINDINGS: The most commonly reported cutaneous findings described for COVID-19 in adults and children were chilblains-like lesions, followed by maculopapular eruption, urticarial lesions, vesicular lesions, and livedoid lesions. Children can also present with erythema multiforme (EM)-like lesions and skin findings associated with multisystem inflammatory syndrome in children (MIS-C). SUMMARY: There are numerous cutaneous manifestations of COVID-19, some of which are unique to children such as EM-like lesions and skin findings for MIS-C. Livedoid lesions do not commonly occur in the pediatric population. In mild cases, supportive care is indicated, whereas severe cases warrant intensive care and hospitalization.

Continuing patient care to underserved communities and medical education during the COVID-19 pandemic through a teledermatology student-run clinic.

A virtual pediatric dermatology student-run clinic was initiated during the COVID-19 pandemic, when in-person educational opportunities were limited. The clinic's aim is to provide high-quality dermatologic care to a diverse, underserved pediatric patient population while teaching trainees how to diagnose and manage common skin conditions. In our initial eight sessions, we served 37 patients, predominantly those with skin of color, and had a low no-show rate of 9.8%. This report describes the general structure of the clinic, goals, and the patient population to provide an overview of our educational model for those interested in similar efforts.

Biological therapy for pustular psoriasis: a systematic review.

BACKGROUND: The anecdotic evidence of the benefits from biologic agents for psoriasis is extensive. However, data on the efficacy of biologic agents for pustular psoriasis are limited. METHODS: To update the data on the efficacy and safety of biologic agents for the management of pustular psoriasis. A systematic review of published data regarding biologic therapies on PubMED database, used in the management of pustular psoriasis from 2012 was undertaken. RESULTS: A total of 209 articles were identified, and 43 articles were selected for inclusion. TNF-α inhibitors were used in 205 patients, and 86 patients received ustekinumab, secukinumab, brodalumab, ixekizumab and IL-1 inhibitors. Overall response was favorable for most modalities. No serious adverse events were reported. Inconsistent measures of treatment response and study variability limited the overall evaluation of data. CONCLUSIONS: Infliximab and ustekinumab have the most evidence of efficacy and safety for the treatment of pustular psoriasis. Recent evidence supports the use of IL-17 antagonists. Prospective controlled and comparative trials are needed to further explore the efficacy and safety of biologic agents in order to establish objective recommendations for the management of this challenging condition.

Case report: first report of a prosthetic joint infection caused by Facklamia hominis.

Facklamia spp. are gram-positive cocci first described in 1997. They are α-hemolytic, facultative anaerobes, catalase-negative cocci, resembling viridians streptococci on 5% sheep blood agar. Facklamia hominis is, by far, the most common species of the 6 so far described, and it is thought that its natural habitat is the female genital tract. Four previous human infections with Facklamia spp. have been documented. We report the first case of a chronic prosthetic joint infection caused by F. hominis and its successful treatment by a 2-stage exchange procedure to eradicate the infection. This is also the first osteoarticular infection reported. The clinical implications are discussed.

Antibiotic susceptibility in gram-positive chronic joint arthroplasty infections: increased aminoglycoside resistance rate in patients with prior aminoglycoside-impregnated cement spacer use.

Two-stage revision using aminoglycoside-cement spacers (A-CSs) is widely used to manage chronic periprosthetic joint infection (PJI). However, aminoglycoside-resistance in gram-positive cocci (GPC) seems to be increasing. Moreover, the contribution of these A-CSs to select resistant mutants is a matter of concern. We study the antibiotic susceptibility profile of GPC after 113 chronic hip and knee PJIs. Aminoglycoside susceptibility-profiles were compared between cases where A-CSs had previously been used (n: 52), and cases of primary infection (n: 61). 32% of isolates were resistant to gentamicin and 40.6% to tobramycin. Gentamicin resistance after previous A-CS use was significantly higher (49.2% [30/61] vs. 19.3% [16/83]; P: 0.0001) as well as with tobramycin (52.7% [29/55] vs. 30.9% [21/66]; P: 0.014). A high rate of gentamicin-tobramycin resistance exists among the most common bacteria involved in chronic-PJI. The risk of selection for aminoglycoside-resistant mutants in cases of infection relapse is a concern following A-CS use.

Industrially prefabricated cement spacers: do vancomycin- and gentamicin-impregnated spacers offer any advantage?

BACKGROUND: Industrially preformed antibiotic-loaded cement spacers are useful to facilitate the second stage of two-stage exchange arthroplasty for infected THAs and TKAs. However, whether gentamicin alone or a combination of antibiotics (such as vancomycin and gentamicin) is more effective is not known. QUESTIONS/PURPOSES: We therefore sought to compare industrially prefabricated spacers containing either gentamicin or gentamicin and vancomycin with respect to (1) infection control, (2) complications, and (3) quality of life, pain, and patient satisfaction. METHODS: We performed a review of 51 patients with chronic infections treated at one center using either gentamicin or vancomycin and gentamicin-prefabricated spacers. The former were used exclusively from January 2006 until May 2009, and the latter from June 2009 until July 2011, and there was no overlap. We collected data on demographics, immunologic status (McPherson classification), prosthetic joint infection location, type of prosthesis, microbiologic results, and time between stages. We evaluated the primary outcome of infection control or recurrence after at least 12 months followup. We also recorded complications. Each patient completed a quality-of-life survey, VAS, and a self-administered satisfaction scale. RESULTS: The overall infection control rate was 83% after a mean followup of 35 months (range, 12.4-64.7 months). There were no differences between gentamicin and vancomycin and gentamicin spacers in terms of infection eradication (80 % versus 85 %, respectively; p = 0.73), nor in terms of complications, quality of life, pain, or satisfaction scores. CONCLUSIONS: Prefabricated, antibiotic-loaded cement spacers has been proven effective for infection control in TKAs and THAs but with the numbers available, we did not find any differences between a gentamicin or vancomycin and gentamicin-prefabricated spacer, and therefore, we are unable to validate the superiority of the combination of vancomycin and gentamicin over gentamicin alone. Because of the higher costs involved with vancomycin and gentamicin spacers, and the potential risks of unselective use of vancomycin, further comparative studies are necessary to evaluate their role in the treatment of infected THAs or TKAs. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Outcome after knee arthrodesis for failed septic total knee replacement using a monolateral external fixator.

PURPOSE: To evaluate the pain level and patient satisfaction as well as the fusion and infection eradication rates after knee arthrodesis using a monolateral external fixator for failed septic total knee replacement (TKR). METHODS: Records of 10 male and 11 female consecutive patients aged 70 to 88 (mean, 81) years who underwent knee arthrodesis using a monolateral external fixator for failed septic TKR were retrospectively reviewed. Each patient had undergone a mean of 3.4 (range, 1-15) procedures. The infection eradication rate, fusion rate, time to achieve fusion, pain level, patient satisfaction, and health-related quality of life were evaluated. RESULTS: Infection was eradicated in 18 (86%) of the 21 patients, whereas fusion was achieved in 17 (81%) of the 21 patients after a mean of 10.3 (range, 4-16) months. Those who did and did not achieve fusion differed significantly in terms of the mean pain score (2.3 vs. 6.4, p=0.031). Compared with age-matched Spanish general population, patients aged >75 years fared significantly worse in terms of the mean physical summary component score (40.7 vs. 34.9, p=0.001). Among those who achieved fusion, 82% were very or somewhat satisfied; none was very dissatisfied. Among those who did not achieve fusion, 75% were very or somewhat dissatisfied. CONCLUSION: Knee arthrodesis using a monolateral external fixator for failed septic TKR achieved high fusion and infection eradication rates, despite the extended time needed. When fusion is achieved, patients had good pain relief and satisfaction.

Antibiotic-impregnated cement spacer as a definitive treatment for post-arthroscopy shoulder destructive osteomyelitis: case report and review of literature.

Arthroscopic revision of rotator cuff lesions is an increasingly popular procedure with a relatively safe profile. However, associated deep articular infection has been described, with potentially destructive joint sequelae. When occurring, it poses the double challenge of eradicating the infectious agent while preserving the articulation and its function. Experience remains scarce and is mostly based on case reports and small series. These also rely on the evidence from the better-described lower extremity joint infections. Through a complex case, the following report addresses this exceptional situation and offers an unusual solution, taking into consideration the peculiarities of the shoulder joint. With the consent of the patient, a single-stage resection arthroplasty with the implantation of an antibiotic-impregnated cement spacer was performed as a long-lasting-if not definite-treatment. After 4 years, the patient maintains excellent function with no radiological signs of wear or loosening.

Two-stage knee arthrodesis using a cemented modular tumour replacement system for recalcitrant septic proximal tibial non-union: a case report.

Knee arthrodesis is an alternative to amputation for treating recalcitrant septic non-union of the proximal tibia with bone loss, soft-tissue compromise, and knee-joint involvement. Nonetheless, arthrodesis is difficult to achieve if bone loss is massive, and the septic environment can result in failed bone fusion. We report on a 77-year-old man with massive bone loss secondary to recalcitrant septic non-union who underwent radical bone resection, followed by knee arthrodesis using a cemented modular intercalary megaprosthesis in conjunction with a microvascularised flap in 2 stages.

Percutaneous interface biopsy in dry-aspiration cases of chronic periprosthetic joint infections: a technique for preoperative isolation of the infecting organism.

PURPOSE: Preoperative identification of the infecting micro-organism is of paramount importance in the treatment protocol for chronic periprosthetic joint infections, as it enables selection of the most appropriate antibiotic treatment. Preoperative joint aspiration, the most commonly used sampling technique, has proven to have a broad range of sensitivity values and the frequency of dry aspirations has not been well assessed. In such dry-tap cases a biopsy sample could be an option. The purpose of this study was to assess the diagnostic accuracy of percutaneous interface biopsy (PIB) in isolating the infecting organism in cases of chronic Periprosthetic Joint Infection (PJI) and dry-tap event. The basic technique is to harvest and culture a sample from the periprosthetic interface membrane by a percutaneous technique in the preoperative period. METHODS: A retrospective study was done involving 24 consecutive patients suspected of PJI and where no fluid was obtained from the joint. Culture results from a percutaneous interface biopsy (PIB) were compared with intraoperative tissue cultures at the time of revision surgery. In all cases, a two-stage replacement was done. RESULTS: The sensitivity was 88.2%; specificity was 100%. Positive predictive value was 100%, while negative predictive value was 77.9%. Accuracy was 91.6%. No technique-related complication was observed. CONCLUSION: We conclude that PIB is a useful test for preoperative isolation of the infecting organism and could play a role in cases with dry-tap joint aspirations.

Update on osteo-articular infections and severe skin and soft tissue infections / Actualización de las infecciones osteoarticulares y las infecciones graves cutáneas y de los tejidos blandos

The present article is an update on bone, joint, skin and soft-tissue infections. A panel of Spanish clinicians including orthopedic surgeons, infectious diseases specialists and microbiologists with extensive experience in these fields have commented on the most relevant medical articles published during the last two years. In the next section, we review and discuss 10 articles on pathogenesis (1), diagnostic methods (1), epidemiology (1) and general management of prosthetic joint infections (8) and three on severe and necrotizing soft tissue infections. Although the rate of joint arthroplasty infection is about 1-3%, the infection of an orthopedic implant is particularly devastating since it requires several interventions, prolonged hospitalization and antibiotic treatment for weeks or months. Taking into account the increasing number of arthroplasties performed each year, a parallel increase is expected in the number of prosthetic joint infections. In the absence of well-designed prospective, randomized, controlled studies, the diagnosis and treatment of prosthetic joint infections is based mainly on personal experience. For these reasons, the authors consider particularly interesting a critical review of the most important references in this field. Recently, emergent pathogens such as community-acquired methicillin-resistant Staphylococcus aureus have been involved in necrotizing fasciitis. In addition, new tools for the diagnosis and treatment of these infections have been described and are now reviewed in the present article

El artículo presente recoge una actualización de las infecciones óseas, articulares, cutáneas y de los tejidos blandos. Un grupo de clínicos españoles constituido por traumatólogos, especialistas en enfermedades infecciosas y microbiólogos con amplia experiencia en estos campos ha comentado los artículos de mayor relevancia a este respecto publicados durante los 2 últimos años. En la sección siguiente se revisan y comentan 10 artículos sobre patogenia (1), métodos diagnósticos (1), epidemiología (1) y abordaje terapéutico general de las infecciones en las prótesis articulares (8); además, se exponen los resultados obtenidos en tres publicaciones sobre infecciones necrosantes graves de los tejidos blandos. A pesar de que la incidencia de infección de las artroplastias es de aproximadamente el 1-3%, la infección de un implante ortopédico es un cuadro especialmente grave debido a que obliga a la realización de varias intervenciones quirúrgicas, a una hospitalización prolongada y a la administración de tratamiento antibiótico durante semanas o meses. Considerando en conjunto el número creciente de intervenciones de artroplastias que se realizan anualmente, se espera un incremento paralelo en el número de infecciones de las prótesis articulares. En ausencia de estudios prospectivos y realizados con asignación aleatoria y control, el diagnóstico y el tratamiento de las infecciones de las prótesis articulares están fundamentados principalmente en la experiencia personal. Por estas razones, los autores consideran especialmente interesante una revisión crítica de las publicaciones más importantes que se han efectuado en este campo. Recientemente se han observado cuadros de fascitis necrosante de origen extrahospitalario causados por Staphylococcus aureus resistente a meticilina. Además, en el artículo presente se revisan las nuevas herramientas introducidas para el diagnóstico y el tratamiento de estas infecciones

Spontaneous pyogenic vertebral osteomyelitis and endocarditis: incidence, risk factors, and outcome.

PURPOSE: The relationship between pyogenic vertebral osteomyelitis and infectious endocarditis is uncertain. This study investigates the incidence and risk factors of infectious endocarditis in patients with pyogenic vertebral osteomyelitis, and the outcome of pyogenic vertebral osteomyelitis with and without associated infectious endocarditis. METHODS: A retrospective record review was conducted of all cases of vertebral osteomyelitis from January 1986 to June 2002, occurring in a tertiary referral hospital. Patients were followed for at least 6 months with careful attention to detection of infectious endocarditis and relapses. RESULTS: Among 606 patients with infectious endocarditis, 28 (4.6%) had pyogenic vertebral osteomyelitis. Among 91 cases of pyogenic vertebral osteomyelitis, 28 (30.8%) had infectious endocarditis. In 6 patients with no clinical signs of infectious endocarditis, the disease was established by routine echocardiography. Infectious endocarditis was more common in patients with predisposing heart conditions and streptococcal pyogenic vertebral osteomyelitis infection. Overall, pyogenic vertebral osteomyelitis in-hospital mortality was 11% (7.1% with infectious endocarditis). Twelve of 25 patients with infectious endocarditis with uncomplicated pyogenic vertebral osteomyelitis were treated for 4 to 6 weeks (endocarditis protocol), with no pyogenic vertebral osteomyelitis relapses. CONCLUSIONS: When specifically sought, the incidence of infectious endocarditis is high in patients with pyogenic vertebral osteomyelitis. Oral therapy may be an option for uncomplicated pyogenic vertebral osteomyelitis; nevertheless, in gram-positive infections, this approach should only be considered after excluding infectious endocarditis. Favorable outcome with shorter treatment in uncomplicated pyogenic vertebral osteomyelitis associated with infectious endocarditis suggests that prolonged therapy may not be needed in this subgroup except for those infected by difficult to treat microorganisms, such as methicillin-resistant Staphylococcus aureus or Candida spp.