Pleural and pericardial effusions with fever and altered mental status: an atypical presentation of bartonellosis.

A male in his 60s presented to the emergency department (ED) with a 3-week history of fever and progressive confusion. Initial laboratory and radiographic workup was largely unremarkable except for moderate bilateral pleural effusions. The patient was admitted on broad-spectrum antibiotics and further workup for fever of unknown aetiology. The differential diagnosis was broadened to different zoonotic infections, and subsequent laboratory testing showed a markedly elevated Bartonella henselae IgG and Bartonella quintana IgG (1:4096 and 1:512, respectively) in addition to positive B. henselae IgM titre (>1:20). During hospitalisation, the patient became more hypoxic and was found to have enlarging pleural effusions as well as a new pericardial effusion. The patient was treated with intravenous then oral doxycycline 100 mg two times per day and oral rifampin 300 mg two times per day for 4 weeks with subsequent improvement in clinical status as well as both effusions. This case highlights a unique presentation of Bartonella and its rare manifestation of pleural and pericardial effusions.

Outpatient Vasectomy: Safe, Reliable, and Cost-effective.

Vasectomy is a safe, effective, and practical option for permanent contraception in men. Vasectomy is a surgical procedure used in men to disrupt and occlude the vas deferens, which delivers sperm from the testicles. By interrupting sperm transport, this procedure provides permanent sterilization. Vasectomies are typically done under local anesthesia in outpatient settings, and patients usually go home within an hour of the surgery. Surgical techniques used for vasectomy vary widely throughout the world, with limited evidence to guide the most effective approach. Current vasectomy guidelines largely rely on information from observational studies, with few controlled clinical trials.

Neonatal Circumcision.

Neonatal circumcision is one of the most common elective surgical procedures in the United States and globally. This procedure, to remove part of the penile prepuce or foreskin, is done for a variety of personal, social, and medical reasons. There are several proposed benefits, risks, and ethical considerations to discuss with parents before the procedure. Three equally safe and effective methods are used for circumcision, and each uses unique equipment: the Gomco clamp, the Mogen clamp, and the Plastibell device. Choice of technique should be guided by operator training and comfort.

Skin Ulcers: Prevention and Diagnosis of Pressure, Venous Leg, and Arterial Ulcers.

Pressure, venous leg, and arterial ulcers are common and costly skin conditions that affect patients in all clinical settings. Clinical features can help differentiate these ulcers. Pressure ulcers are associated with restricted mobility, poor perfusion, and compromised skin status. Venous leg ulcers (VLUs) are attributed to chronic venous hypertension resulting from venous insufficiency or obstruction. Risk factors for a first VLU include previous nonvenous leg ulcer, male sex, chronic venous hypertension, and older age. Arterial ulcers result from skin and soft tissue ischemia due to arterio-occlusive disease. They are associated with hypertension, diabetes, chronic kidney disease, and smoking. Various methods of pressure offloading have strong evidence of effectiveness in prevention of pressure ulcers. Clinical practice guidelines support the use of compression therapy in patients with previous VLUs to prevent ulcer recurrence. For patients with chronic lower extremity ulcers, a crucial step in evaluation is measurement of the ankle-brachial index, which can identify decreased perfusion and indicate the need for referral to a vascular surgeon. The likelihood of bone involvement should be determined. Skin and soft tissue infections often complicate wound care and should be addressed at each patient evaluation. Various factors can predict likelihood of wound healing.

Skin Ulcers: Wound Management.

For patients with chronic ulcers, the primary management goal, when possible, is complete wound healing. When this is not possible, palliative wound care provides a patient-centered alternative. Malnutrition is a risk factor for pressure ulcer development, but it is unclear whether interventions improve wound healing or other outcomes. Debridement is the removal of nonviable tissue, foreign bodies, and biofilm from the wound bed to eliminate physical and microbiologic impediments to healing. Nonsurgical debridement options include autolytic, enzymatic, biologic, and mechanical methods. The ideal dressing provides moisture to the wound and dryness to the periwound area. Choice of dressing is based primarily on exudate management properties. Pressure offloading is considered the primary therapy for pressure ulcers but strong evidence to support its use is lacking. For patients with venous leg ulcers (VLUs), unless contraindicated, compression therapy is a recommended component of the management plan. There is insufficient or poor-quality evidence supporting the effectiveness of negative pressure wound therapy and hyperbaric oxygen therapy in the management of pressure ulcers, VLUs, and arterial ulcers. Family physicians play a central role in the management of chronic ulcers, providing aggressive risk factor modification, control of chronic conditions, and prompt referral when indicated.

Skin Ulcers: Pharmacotherapy.

Topical wound therapies have unclear benefits for patients with pressure ulcers, venous leg ulcers (VLUs), and arterial ulcers. There is slightly more evidence supporting the use of systemic therapies. Used with compression therapy or alone, oral pentoxifylline has been shown to be more effective than placebo or no therapy in improving and healing VLUs. (This is an off-label use of pentoxifylline.) To prevent bacterial resistance, most guidelines recommend use of antimicrobial dressings, antiseptics, and antibiotics only for patients with infected wounds. There is insufficient evidence to conclude that antiseptics or topical antibiotics improve or heal pressure ulcers and VLUs more effectively than nonmedicated dressings. Systemic antibiotics are used for patients with nonhealing wounds when the clinical infection is not improving with antiseptics or topical antibiotics. After the underlying cause of a chronic wound is addressed, pain management should start with topical drugs. When pain is not managed with topical drugs, systemic drugs should be considered. Opioids should be used only if the overall benefits outweigh the risks. Nutritional supplementation has not been clearly shown to prevent or manage chronic ulcers.

Skin Ulcers: Surgical Management.

Surgical debridement refers to the use of sharp instruments to remove devitalized tissue from wounds. Skin grafting is an adjunctive therapy that uses human (autograft or allograft), nonhuman (xenograft), or artificial (synthetic graft) skin to cover nonhealing ulcers. Bilayer artificial skin plus compression is more effective for venous leg ulcers (VLUs) than standard dressings plus compression. Reconstructive surgery provides options for coverage of deep, refractory pressure ulcers; however, no randomized trials have compared these techniques with standard care. For patients with VLUs with superficial venous reflux, early endovenous ablation plus compression heals VLUs more quickly than compression with deferred ablation. Revascularization restores in-line arterial flow to ischemic extremities, facilitating wound healing and pain resolution. Bypass surgery has been shown to result in better luminal patency at 1 year than percutaneous transluminal angioplasty (PTA), but PTA is associated with fewer perioperative complications and shorter hospitalizations. PTA with and without stenting are comparable in terms of rates of perioperative complications and major amputation and mortality in patients with infrapopliteal arterio-occlusive disease. Amputation is the last option for patients with critical limb ischemia who are not candidates for or have not benefited from revascularization attempts.

Common Skin Conditions in Children: Neonatal Skin Lesions.

Skin findings during the initial month of life are ubiquitous. One study estimated that more than 95% of newborns have cutaneous findings, which often are distressing to parents but frequently are benign and self-limited. Among them are milia, cutis marmorata, congenital dermal melanocytosis, and the benign neonatal pustular eruptions (eg, benign cephalic pustulosis, erythema toxicum neonatorum, transient neonatal pustular melanosis). Clinicians need to recognize these benign skin conditions and differentiate them from more serious conditions, such as infectious pustular eruptions from bacterial, viral, and fungal causes, and inflammatory conditions, such as Langerhans cell histiocytosis. Notable bacterial pustular eruptions are bullous impetigo and congenital syphilis. Viral pustular dermatoses include neonatal herpes simplex virus infection and varicella zoster virus infection, which consists of congenital varicella syndrome, perinatal varicella, and infantile zoster. Fungal pustular eruptions include congenital and neonatal candidiasis. Seborrheic dermatitis is a self-limited condition that occurs with varying severity; symptomatic treatment is reserved for the more severe forms. Diaper dermatitis encompasses a broad clinical diagnosis, including allergic and irritant contact dermatitis, atopic dermatitis, infections, psoriasis, and other dermatologic conditions. Critical components of newborn skin care are immersion bathing, umbilical cord care, and use of emollients to augment skin barrier function.

Common Skin Conditions in Children: Skin Infections.

Skin infections account for a significant subset of dermatologic conditions of childhood. Common cutaneous viral infections in children include warts, molluscum contagiosum, hand-foot-and-mouth disease, and herpes simplex. Although viral infections are self-limited and often only mildly symptomatic, they can cause anxiety, embarrassment, and health care use. Recognition of their common and atypical presentations is necessary to differentiate them from other skin conditions of similar morphology. Impetigo, cellulitis, and abscess comprise the majority of childhood bacterial skin infections and are treated with topical or systemic antibiotics that cover group A Streptococcus and Staphylococcus aureus. Common fungal dermatologic infections in children are oral and genital candidiasis, tinea capitis, and tinea corporis. Management consists of topical and systemic antifungals, including nystatin, triazoles, terbinafine, griseofulvin, and imidazoles. Scabies is the most common parasitic skin infection among children and is managed with topical permethrin. Although serious illness is not common among children returning from international travel, patients presenting with fever and rash, especially petechial or hemorrhagic lesions, require thorough evaluation. Of the numerous reportable conditions that present with childhood rash, tick-borne illnesses, measles, rubella, and varicella are the most common.

Common Skin Conditions in Children: Noninfectious Rashes.

Cutaneous adverse drug reactions are among the most common noninfectious rashes of childhood. Cutaneous adverse drug reactions are classified as morbilliform, urticarial, bullous, pustular, or psoriasiform. Atopic dermatitis is one of the most common inflammatory cutaneous eruptions, and is characterized by pruritus and flexural distribution. Emollients and topical corticosteroids are first-line therapies. Topical calcineurin inhibitors are second-line, steroid-sparing drugs for certain conditions, such as face and eyelid eczema. Systemic and immunologic conditions have mucocutaneous features, such as malar rash, discoid lupus, and photosensitivity in systemic lupus erythematosus; lip, oral, and extremity changes as well as polymorphous rash in Kawasaki disease; erythematous, scaly plaques in psoriasis; and xerosis and face, hand, and leg skin changes in type 1 diabetes. Genetic conditions that manifest as changes in skin pigmentation are important to recognize because of the thorough diagnostic evaluation they warrant, the often challenging interventions they necessitate, and the permanent disability that frequently accompanies them. These conditions include neurofibromatosis, LEOPARD syndrome, incontinentia pigmenti, congenital hemidysplasia with ichthyosiform erythroderma and limb defects syndrome, hypomelanosis of Ito, and acanthosis nigricans. Childhood dermatologic emergencies often are associated with infection and drugs and require early recognition and intervention.

Common Skin Conditions in Children: Congenital Melanocytic Nevi and Infantile Hemangiomas.

Congenital melanocytic nevi (CMN) are hamartomas present at birth that are composed of nevomelanocytes and thought to originate from faulty migration of precursor melanocytes in the neural crest. Classification is based on projected adult size of the lesion. CMN size correlates positively with risk of melanoma and neurocutaneous melanocytosis. Management requires a patient-centered approach that weighs the risks and benefits of and alternatives to complete removal. All children with large and giant CMN, regardless of surgical status, should be monitored closely and undergo periodic skin examination. Infantile hemangiomas (IHs) are vascular neoplasms arising from endothelial cell hyperplasia that go through proliferative (growth) and involutional phases. Large, segmental IHs carry a higher risk of bleeding, and patients with these IHs may benefit from imaging. Small, focal IHs in noncritical areas do not require treatment. In contrast, early referral and treatment should be considered for patients with large, extensive, deep, segmental, or syndromic IHs. Systemic and topical beta blockers have the strongest efficacy data and have replaced systemic and intralesional corticosteroids as first-line treatment for IHs in the United States. Surgical therapies are second-line modalities, with laser treatment being used most widely.

9 tips to help prevent derm biopsy mistakes.

The authors--with expertise in dermatology and pathology--provide pointers that can help you improve your approach to skin biopsy.

Common questions about vasectomy.

Vasectomy offers a safe, effective, and permanent method of male contraception, with an overall failure rate of less than 1% in pooled studies. Men older than 30 years in a stable, committed relationship appear to be the best candidates for vasectomy. The no-scalpel technique reduces operative complications, shortens operative time, and hastens resumption of sexual activity. Use of a jet injector instead of a needle to provide local anesthesia (no-needle vasectomy) may reduce pain. Bleeding and infection are short-term complications of vasectomy; long-term complications include sperm granuloma and postvasectomy pain syndrome. One postvasectomy semen analysis demonstrating azoospermia performed after three months and 20 ejaculations is sufficient to establish sterility. Vasectomy reversal is more likely to be successful if performed less than 15 years after vasectomy and in men whose female partner is younger than 40 years.