Tuberculoid Leprosy Masquerading as Erythema Induratum.

Introduction: Erythema Induratum (EI) is a relatively rare dermatologic disorder affecting subcutaneous fat tissue, which is often associated with Mycobacterium tuberculosis. This report details the presentation, diagnosis and management in a 70-year-old female who presented with a painful erythematous annular rash at the clinic. The rash was later diagnosed as EI associated with Mycobacterium leprae, one rarely seen in literature. Discussion: EI is a rare form of panniculitis that typically presents as a recurrent grouping of tender nodules and plaques on the posterior aspect of the lower legs. Although EI is considered idiopathic in most cases, it can be associated with M. leprae. Given the atypical presentation of a rash, a biopsy was done. It showed epithelioid granulomatous dermatitis with lobar panniculitis. A DNA polymerase chain reaction (PCR) was also sent and revealed the presence of M. leprae. Treatment of EI without association with M. leprae includes potassium iodide, non-steroidal anti-inflammatory drugs (NSAIDs), rest, elevation, compression and, in severe cases, systemic immunosupressives. If tuberculoid leprosy is confirmed, the attending physician is encouraged to consult the infectious disease department as treatment varies with presentation. Conclusions: This case details the diagnosis and management involved in a case of tuberculoid leprosy masquerading as EI. Management of the EI involved NSAIDs and potassium iodide. The leprosy was treated with dapsone and rifampin in conjunction with an infectious disease consultation. Our case highlights the importance of relying on a strong clinical suspicion based on a patient's social history in order to diagnose rare entities accurately.

Short versus long course of antibiotics for catheter-associated urinary tract infections in patients with spinal cord injury: a randomized controlled noninferiority trial.

OBJECTIVE: To assess the applicability of a short-course regimen of antibiotics for managing catheter-associated urinary tract infection (CA-UTI) in patients with spinal cord injury (SCI). DESIGN: Randomized, controlled, noninferiority trial. SETTING: Medical center. PARTICIPANTS: Patients with SCI who had CA-UTI (N=61). INTERVENTIONS: Patients were randomized to receive either a 5-day regimen of antibiotics after catheter exchange (experimental group) or a 10-day regimen of antibiotics with catheter retention (control group). Noninferiority was prespecified with a margin of 10%. MAIN OUTCOME MEASURE: Clinical cure at the end of therapy. RESULTS: Of the 61 patients enrolled in this study, 6 patients were excluded because of bacteremia or absence of urinary symptoms. All patients (100%) achieved clinical cure at the end of therapy. The rates of microbiologic response were 82.1% in the experimental group and 88.9% in the control group (upper boundary 95% confidence interval (CI) for difference, 26%). The rates of resolution of pyuria were 89.3% in the experimental group and 88.9% in the control group (upper boundary 95% CI for difference, 16%). Patients in the experimental group had higher rates of CA-UTI recurrence than the control group. The rates of new CA-UTI, diarrhea, and Clostridium difficile colitis were similar in the 2 treatment arms. CONCLUSIONS: The primary endpoint of the study was met, indicating that the 5-day regimen with catheter exchange was noninferior to the 10-day regimen with catheter retention on the basis of clinical cure. Criteria for noninferiority on the basis of microbiologic response and resolution of pyuria were not met.

Infectious complications associated with percutaneous nephrostomy catheters: do we know enough?

The percutaneous nephrostomy catheter (PCNC) has evolved since its inception. Over more than half a century, it has gone from a temporary maneuver to a permanent fixture in a large proportion of patients who have incurable illnesses with obstructed renal drainage systems. Unfortunately, the research looking specifically at infectious complications associated with PCNCs suffers from oversimplification as studies predominantly assess sepsis alone. There are no standardized definitions or criteria to define the various infectious complications described in this paper. Although the PCNC has a relative paucity of infectious complications, which represents an excellent marker for patient care, the low rate of infection dictates a large sample size for sufficiently-powered research studies to be able to find a significant impact of interventional measures. In this review article, we discuss various aspects of pathogenesis and treatment of the different subtypes of PCNC-associated infections.

New strategies to prevent catheter-associated urinary tract infections.

Catheter-associated urinary tract infection (CAUTI) is the most common health-care-associated infection worldwide. Although not all cases of bacteriuria result in clinical infection, several hundred thousand episodes of CAUTI occur each year in the USA alone. The milieu in which the catheter is placed is highly conducive to bacterial colonization, biofilm formation on the catheter surface, and inevitable catheter-associated bacteriuria. A multitude of novel methods of CAUTI prevention have been described, including established approaches that are routinely recommended, such as the use of a secured, closed, silicone urinary catheter drainage system that mimics normal voiding, and newer strategies focusing on biocompatible catheter materials that cause minimal host inflammatory response and retard biofilm formation. Much recent research has focused on modification of the catheter surface by either coating or impregnation with antimicrobials or antiseptics. However, clinical trials that analyse cost-effectiveness and rates of antimicrobial resistance are awaited. More recently, innovative use of iontophoresis, vibroacoustic stimulation, bacterial interference and bacteriophage cocktails has been reported.

Nanoscale surface modification favors benign biofilm formation and impedes adherence by pathogens.

We have found in vitro that a biofilm of benign Escherichia coli 83972 interferes with urinary catheter colonization by pathogens, and in human studies E. coli 83972-coated urinary catheters are associated with lower rates of catheter-associated urinary tract infections. We hypothesized that modifying surfaces to present mannose ligands for the type 1 fimbriae of E. coli would promote formation of dense E. coli 83972 biofilms, thereby interfering with surface colonization by Enterococcus faecalis, a common uropathogen. We covalently immobilized mannose on silicon substrates by attaching amino-terminated mannose derivative to carboxylic acid-terminated monolayers via amidation. Fluorescence microscopy showed that E. coli 83972 adherence to mannose-modified surfaces increased 4.4-fold compared to unmodified silicon surfaces. Pre-exposing mannose-modified surfaces to E. coli 83972 established a protective biofilm that reduced E. faecalis adherence by 83-fold. Mannose-fimbrial interactions were essential for the improved E. coli 83927 adherence and interference effects. From the Clinical Editor: Recurrent urinary tract infections remain major adverse events associated with catheter use. The authors report that modifying catheter surface to present mannose ligands for the type 1 fimbriae of benign Escherichia coli 83972 promotes formation of dense E. coli biofilms, which 100-fold reduces urinary catheter colonization of uropathogens. Future application of this technology is expected to result in substantial UTI risk reduction in catheter users.

Norovirus gastroenteritis successfully treated with nitazoxanide.

Infectious diarrhea is a common occurrence in the immunosuppressed population. We present a 43-year-old individual with large-volume stool output Norovirus acute gastroenteritis in the setting of relapsed refractory acute myelogenous leukemia, hematopoietic stem cell transplantation, and biopsy-proven cutaneous and pulmonary graft-versus-host disease. Therapeutic options such as intravenous immunoglobulin or reduction of immunosuppressants were not a feasible choice. A prompt clinical cure was achieved with nitazoxanide, a broad-spectrum antimicrobial agent. Nitazoxanide may be a safe therapeutic alternative, in which a reduction in immunosuppression may not be a viable option.