Factors that affect the duration of antimicrobial therapy for cellulitis.

BACKGROUND: The recommended duration of antibiotic therapy for patients hospitalized with cellulitis is 5-14 days. However, factors that affect the duration of treatment have rarely been examined. METHODS: We conducted an observation study in a regional hospital in Japan to examine factors that affect the duration of antibiotic therapy for cellulitis. Our study included 102 patients with cellulitis of the lower extremities who were treated with intravenous cefazolin alone. Intravenous cefazolin was terminated when redness, swelling, and tenderness of the lower extremities disappeared, and subsequently the patients were discharged. The relationship between the duration (days) of treatment with intravenous cefazolin (DIVC) and clinical factors were analyzed. RESULTS: The median DIVC was 8 days (interquartile range, 7-10 days). On univariate analysis, DIVC correlated significantly with patient age (P = 0.0071) and with C-reactive protein levels before treatment (P = 0.0053). DIVC in patients with diabetes mellitus was significantly longer than that in patients without diabetes mellitus (P = 0.0033). DIVC in patients with blood stream infection was significantly longer than that in patients without blood stream infection (P = 0.029). On multivariate analysis, variables independently associated with longer DIVC included patient age (P = 0.044), C-reactive protein levels before treatment (P = 0.017), presence of diabetes mellitus (P = 0.0021), and presence of blood stream infection (P = 0.028). CONCLUSIONS: Duration of treatment with intravenous antibiotics for cellulitis is associated with patient age, C-reactive protein levels, coexisting diabetes mellitus, and coexisting blood stream infection. These findings should be considered when treatment plans for cellulitis are devised.

Case of dermatophyte abscess caused by Trichophyton rubrum: a case report and review of the literature.

A 54-year-old Japanese man without apparent immunosuppression presented with nodules with purulent drainage on the right lower leg. He had ringworm of the right leg and tinea unguium. A biopsy specimen of the nodule showed intradermal abscesses with fungal elements, and Trichophyton rubrum was cultured from both the pus and the biopsy specimen. Treatment with oral terbinafine resolved the nodules. Dermatophyte abscess is a rare, deep and invasive dermatophytosis, which is often associated with immunocompromised conditions. We provide a review of the literature including Japanese cases.

Spitz nevus on the sole of the foot presenting with transepidermal elimination.

A 10-year-old Japanese girl presented with a rhomboid-shaped brown macule, 4x3 mm in size, on the sole of the right foot. Dermoscopic examination revealed a number of black dots and globules on the ridges of the skin, marking an area of symmetrical brown pigmentation. On the periphery, a streak-like arrangement of black dots/globules on the brown pigmentation was observed along the ridges, simulating a "starburst" pattern. The lesion was excised and histological examination showed a symmetrical wedge-shaped compound melanocytic lesion that consisted of junctional and intradermal nests of a mixture of large spindle and epithelioid cells. None of the cells were atypical, and maturation of the cells with increasing depth was observed. From these findings, a diagnosis of Spitz nevus was made. Transepidermal elimination of nevus cell nests was observed and there were small groups of degenerated melanin-laden cells in the cornified layer. Masson Fontana stain revealed fine melanin deposits in the nevus cells of the junctional and intradermal nests, as well as heavy melanin deposits in the small groups of degenerated cells in the cornified layer. The distribution of melanin may contribute to a unique dermoscopic finding in this case.

Development of bullous pemphigoid after change of dialysis membrane.

A 75-year-old Japanese man presented with pruritic blisters and macules on his trunk and extremities. He had been on hemodialysis for 4 years because of chronic renal failure, and in recent months, a polymethylmethacrylate membrane had been used for dialysis. After a change in dialysis membrane to a cellulose triacetate membrane, pruritic tense blisters developed on the extremities in combination with marked blood eosinophilia. Physical examination showed erythematous macules and tense blisters on the trunk and extremities. A biopsy specimen of an erythematous macule showed subepidermal vesicles and eosinophils that attached to the dermal-epidermal junction. Serum level of eosinophilic cationic protein was elevated. From clinical, histological, and immunological findings, a diagnosis of bullous pemphigoid was made. New blisters continued to erupt during the period in which the patient used the cellulose triacetate membrane dialyzer, and even after the use of clobetasol propionate. It resolved only after the patient came back to the use of a synthetic membrane dialyzer. We discontinued the use of clobetasol propionate, and neither bullous eruptions nor blood eosinophilia recurred. These observations suggest that cellulose membrane may be involved in the development of bullous pemphigoid through activation of eosinophils in the blood and the skin lesion, as in the present case.

Bullous pemphigoid with a prolonged prodrome.

Bullous pemphigoid is an autoimmune blistering skin disease of the elderly that may be preceded by a pruritic, urticarial or eczematous eruption. We report a case of bullous pemphigoid preceded by prodromal eczematous eruptions that lasted an unusually long time of 11 years. Elderly patients with persistent pruritic or eczematous eruption of unknown etiology should be carefully followed, as bullous pemphigoid may be a potential diagnosis.

Antiphospholipid antibodies in patients with autoimmune blistering disease.

OBJECTIVE: Our purpose was to determine the serum levels and frequency of antiphospholipid antibodies (aPLs) and confirm the clinical importance of these antibodies in patients with autoimmune blistering disease (ABD). METHODS: IgG and IgM anticardiolipin antibodies (aCL), IgG anticardiolipin-beta(2) glycoprotein I complex antibody (aCL/beta(2)GPI), and IgG antiphosphatidylserine-prothrombin complex antibody (aPS/PT) were examined with an enzyme-linked immunosorbent assay in 71 patients with ABD, including pemphigus vulgaris, pemphigus foliaceus, and bullous pemphigoid. RESULTS: The prevalence of IgG aCL, IgM aCL, aCL/beta(2)GPI, and IgG aPS/PT was positive for 22.4%, 9.1%, 9.9%, and 25.4% of the ABD patients, respectively, whereas these antibodies were not detected in any of the normal control subjects. Ten of 20 patients with ABD who were attending our hospital in 2004 tested positive for aPLs, and thromboembolism was detected in 7 of 10 patients with aPLs. LIMITATIONS: Follow-up studies, especially with a large patient group, will be needed to clarify the clinical relevance of aPLs in ABD. CONCLUSION: aPLs are frequently detected in patients with ABD. Careful examination and follow-up for thromboembolism may be necessary in ABD patients with aPLs.