Lucio Phenomenon: An Unusual Case of Skin Necrosis.

Introduction: Lucio leprosy is a non-nodular diffuse type of lepromatous leprosy first described by Lucio and Alvarado. Lucio phenomenon is a rare vasculonecrotic reaction characterized by cutaneous necrosis with minimal constitutional features. Case Presentation: We describe an unusual case of a 53-year-old man from Central India who had blisters, ulcers, and widespread erosions on his foot, forearms, and arms. The diagnosis of lepromatous leprosy with the Lucio phenomenon was established after thorough evaluation by clinical findings, histopathological findings, and slit-skin smear examination. Conclusion: Lucio phenomenon is an uncommon cause of cutaneous infarction and necrosis. Primary care physicians should keep a high index of suspicion in patients with cutaneous necrosis and minimal constitution features. Since leprosy is a relatively curable disease, primary care physicians should think of a rare form of lepromatous leprosy presenting with cutaneous necrosis, especially in non-endemic zones.

Cutaneous Necrosis of the Skin Secondary to Methicillin-Resistant Staphylococcus aureus (MRSA) and Bacteroides With Superimposed Herpes Simplex Virus Type II (HSV-II) in the Setting of Infective Endocarditis.

Herpes simplex virus type II (HSV-II) with superimposed bacterial skin infection is an uncommon presentation of cutaneous necrosis in the setting of infective endocarditis. This case reflects a unique presentation of an immunosuppressed patient with infective endocarditis complicated by septic emboli and cutaneous skin lesions attributable to HSV-II and superimposed bacterial skin infection. The patient presented from an outside hospital with symptoms consistent with acute onset heart failure and skin lesions. Transthoracic and transesophageal echocardiography performed there demonstrated focal thickening of the anterior mitral valve leaflet with severe mitral regurgitation. The patient then underwent extensive infectious work-up and was put on broad-spectrum antibiotics. Further work-up demonstrated greater than three DUKE minor criteria and reiterated the focal thickening of the anterior leaflet of the mitral valve, making infective endocarditis the most likely etiology. Biopsies of the skin lesions were performed which stained positive for HSV-II and grew methicillin-resistant Staphylococcus aureus and Bacteroides fragilis. The cardiothoracic surgery service ultimately decided not to perform any surgical intervention to the mitral valve during her hospitalization as she was deemed to be too high of a risk due to her thrombocytopenia and significant comorbidities. She was later discharged in hemodynamically stable condition on long-term intravenous antibiotics with repeat echocardiography demonstrating significant reduction in the mitral regurgitation and the focal thickening of the anterior leaflet of the mitral valve.

Skin necrosis and calcifications after extravasation of vancomycin: a localised form of calciphylaxis?

Vancomycin is a tricyclic glycopeptide antibiotic produced from Streptococcus orientalis. There is much variation in the literature with regard to the recommended dose, dilution rate and type of infusion. Given the vesicant properties of vancomycin at supratherapeutic doses (>10mg/ml), tissue damage including blistering and necrosis have been reported. We report a rare case of bilateral cutaneous necrosis induced by accidental extravasation of vancomycin when being intravenously administered. The skin surrounding the injection site was marked by the appearance of subcutaneous calcifications. The development of iatrogenic skin calcinosis has not yet been described for the extravasation of vancomycin. The mechanism underlying the calcinosis observed in our case remains unclear, but we hypothesised a form of localised calciphylaxis induced by a local triggering factor. The ulcers progressed to re-epithelialisation following necrosis debridement and local conservative treatments. Given the increased prevalence of meticillin-resistant Staphylococcus aureus, which has prompted clinicians to gradually increase vancomycin dosage, clinicians should be aware of the high risk of skin toxicity in cases of vancomycin high-dose extravasation.

Cutaneous necrosis of the arteriovenous fistula puncture site in chronic hemodialysis: A historical complication or an ever-present threat? A series of 26 cases.

INTRODUCTION: Cutaneous necrosis (CN) at the puncture site of the arteriovenous fistula (AVF) in chronic hemodialysis (CHD) is a rare but potentially fatal complication. The objective of our work was to establish the associated complications, vascular prognosis, and patient survival of CHD patients presenting cutaneous necrosis. METHODS: This retrospective study (January 2016 to March 2020) was conducted in the Department of Vascular Surgery and the Department of Nephrology at the University Hospital Center Mohammed VI of Oujda, Morocco. Included were all CHD patients admitted for treatment of cutaneous necrosis at the puncture site of a native AVF. RESULTS: Data from 26 cases were collected. The mean age was 58.7 ± 16 years, 70.8% were female, and 25% had diabetic nephropathy; 42.3% of the AVFs were radiocephalic and 46.1% were brachiocephalic; 42.2% of patients presented active bleeding, of whom 91% required a blood transfusion; 80.8% of the AVFs were complicated by aneurysms. Fistulography showed stenosis in 42.3% of cases. Urgent surgical intervention was performed on all the patients. Fifty percent of patients required placement of a short-term hemodialysis catheter. Two patients had presented a recurrence. Death occurred in one case following a massive hemorrhagic shock. CONCLUSION: Cutaneous necrosis is a relatively common complication and requires early screening and immediate surgical intervention.

[Calcific uremic arteriolopathy in hemodialysis patient, review of literature through five cases reports]. / L'artériolopathie urémique calcifiante de l'hémodialysé chronique, revue de la littérature à travers cinq cas cliniques.

Calcific uremic arteriolopathy, also called calciphylaxis, is a rare and severe disorder that presents with skin ischemia and necrosis, sometimes it presents with systemic necrosis, the process is secondary to the obliteration of the arterioles first by sub-intimal calcium deposits and then by thrombosis. These lesions can often lead to death due to infectious complications and comorbidities such as diabetes, obesity, arteritis, diffuse vascular calcifications, heart disease and undernutrition. The diagnosis is suggested by the characteristic ischemic skin lesions and their distribution, often bilateral and painful, associeted with calcific uremic arteriolopathy risk factors (phosphocalcic abnormalities, anti-vitamin K). The presence of radiological vascular calcifications is highly suggesting the diagnosis, but remains not very specific. The indication of skin biopsy is rare and reserved for difficult diagnoses. The goals of treatment are: reduce the extension of calcification and treatment of mineral and bone metabolism disorders of end-stage renal disease, dialysis adequacy, local treatment of skin lesions, tissue oxygenation, pain management, discontinuation and contraindication of medications that may contribute to the disorder. We propose to discuss it from a review of the literature and illustrate it with five clinical cases.

Acute Cutaneous Necrosis: A Guide to Early Diagnosis and Treatment.

Acute cutaneous necrosis is characterised by a wide range of aetiologies and is associated with significant morbidity and mortality, warranting complex considerations in management. Early recognition is imperative in diagnosis and management of sudden gangrenous changes in the skin. This review discusses major causes of cutaneous necrosis, examines the need for early assessment, and integrates techniques related to diagnosis and management. The literature, available via PubMed, on acute cutaneous necrotic syndromes was reviewed to summarise causes and synthesise appropriate treatment strategies to create a clinician's guide in the early diagnosis and management of acute cutaneous necrosis. Highlighted in this article are key features associated with common causes of acute cutaneous necrosis: warfarin-induced skin necrosis, heparin-induced skin necrosis, calciphylaxis, pyoderma gangrenosum, embolic phenomena, purpura fulminans, brown recluse spider bite, necrotising fasciitis, ecthyma gangrenosum, antiphospholipid syndrome, hypergammaglobulinemia, and cryoglobulinemia. This review serves to increase recognition of these serious pathologies and complications, allowing for prompt diagnosis and swift limb- or life-saving management.

Distribution and medical aspects of Loxosceles rufescens, one of the most invasive spiders of the world (Araneae: Sicariidae).

Loxosceles rufescens is a circum-Mediterranean spider species, potentially harmful to humans. Its native area covers the Mediterranean Basin and Near East. Easily spread with transported goods, it is meanwhile an alien and invasive species to nearly all other continents and many islands. This species occurs in semi-arid steppe-like habitats, typically under stones and in cavities, which enables it to settle inside buildings when invading the synanthropic environment. This review analyses the literature of L. rufescens bites to humans (38 publications) of which only 11 publications refer to 12 verified spider bites (11% of the reported bites). Two published allegedly deadly spider bites (Thailand 2014 and Italy 2016) involve non-verified spider bites and are thus not reliable. The symptoms and therapy of these 11 verified bites are described: only five cases showed moderate systemic effects, nine cases developed necrosis, four cases needed surgical debridement, all cases healed without complications within a few weeks. In conclusion, L. rufescens is a spider species globally spread by human activity, it rarely bites humans and the bites are less harmful than often described. There is no known fatal issue.

Nasal Skin Necrosis: A Very Rare Manifestation of Antiphospholipid Syndrome.

A 23-year-old woman, a smoker and oral oestrogen user, presented with nasal necrosis. No other symptoms or local trauma were described. Relevant laboratory findings included complement consumption, positive lupus-anticoagulant assay, increased rheumatoid factor and positive cryoglobulins. Screening for autoimmune conditions, haematological malignancies and infectious diseases was negative. Histological examination of the nasal skin showed small vessel occlusion without vasculitis. Later, a second positive lupus-anticoagulant assay supported the diagnosis of antiphospholipid syndrome. The patient improved with glucocorticoids and anticoagulation. This case report describes an unusual manifestation of antiphospholipid syndrome in a patient with cryoglobulinaemia contributing to the thrombotic event and highlights the importance of recognizing these overlapping disorders. LEARNING POINTS: Nasal skin necrosis is an uncommon event with a wide spectrum of aetiologies.The rare association of antiphospholipid syndrome with cryoglobulinaemia may act synergically in small-medium vessel occlusion, with skin involvement being the most common manifestation.Anticoagulation and immunosuppression of antiphospholipid syndrome with cryoglobulinaemia is mandatory.

[Emergency management of extravasation in children]. / L'extravasation chez l'enfant, prise en charge en urgence.

The subcutaneous diffusion of intravenous drips, or extravasation, is a frequent iatrogenic complication in children, mainly in the neonatal period. This potentially severe pathology can lead to local ischemia that sometimes mimics compartment syndrome. It can also evolve towards vast soft-tissue necrosis. Nursing staff often underestimate the risk of functional, aesthetic, and psychological consequences. The speed and quality of the initial medical and surgical management can greatly decrease morbidity associated with extravasation. Prevention is fundamental, such as raising awareness in and training medical and paramedical staffs and creating efficient protocols. Surgical management involving aspiration and washing the site as early as possible improves the prognosis. Aspiration and washing can be done on a larger area if one criteria of severity is met, particularly in cases of extravasation using a vesicant or hyperosmolar agent. If necrotic lesions appear, it is wise to wait until they become delimited. Debridement and coverage can be performed using classical methods.

Treatment of traumatically cutaneous necrosis of buttocks using vacuum sealing drainage combined with ileostomy.

PURPOSE: The purpose of this study is to evaluate the surgical technique and review the therapeutic effect of vacuum sealing drainage combined with ileostomy treating patients of traumatically buttock skin necrosis. METHODS: 26 patients with buttock wounds were dressed and 6-12 days later, buttock skin necrosis boundaries were clear and debridement was performed. General surgeons were invited to perform the ileostomy. Thorough debridement was conducted and vacuum sealing drainage (VSD) devices were used to cover buttock wounds. Debridement and VSD were operated every 5-7 days until the granulation tissue of buttock wound was fresh. Then epidermal skin graft from thigh was performed to cover the granulation wound. About 3 months later after skin graft survival completely, the ileum was reversed by general surgeons and the patients recovered defecation using anus. RESULTS: The granulation tissues of all patients were fresh after debridement and VSD 2-3 times. In 20 cases, transplanted epidermal skin grew well. In six cases, necrosis was observed at the margins of the flap and further debridement and skin graft were conducted. During the follow-up period of approximate 6 months, the flaps grew well and the patients defecated normally from anus. CONCLUSIONS: Treating traumatically cutaneous necrosis of buttocks with vacuum sealing drainage and ileostomy can gain good therapeutic effect.

Cutaneous necrosis as a result of isosulphane blue injection in mammarian sentinel lymph node mapping: report of two cases.

Skin-sparing mastectomy with sentinel lymph node biopsy (SLNB) and synchronous breast reconstruction are widely used in breast cancer surgery nowadays. Difficulties in feeling confident in this technique and postoperative surgical complications are the major obstacles against the widespread usage of this technique. Compared with the other surgical techniques, the complications are hard to treat. Cutaneous necrosis because of methylene blue used for sentinel lymph node mapping in patients who underwent skin-sparing mastectomy and SLNB is already reported in the literature. We present here two cases with cutaneous necrosis because of isosulphane blue injection after skin-sparing mastectomy and SLNB as a rare complication of dye injection.

Characteristics, prognosis, and outcomes of cutaneous ischemia and gangrene in systemic necrotizing vasculitides: a retrospective multicenter study.

OBJECTIVES: To describe the prevalence, characteristics, and outcome of cutaneous ischemia, and whether it can occur in systemic necrotizing vasculitides (SNVs), i.e., polyarteritis nodosa, granulomatosis with polyangiitis, and eosinophilic granulomatosis with polyangiitis and microscopic polyangiitis. METHODS: We conducted a retrospective analysis of all patients with SNV who were included in the French Vasculitis Study Group cohort database between March 1963 and September 2007. We compared characteristics and outcomes for patients with and without cutaneous ischemia (digital necrosis and/or isolated necrotic cutaneous ulcers). RESULTS: Among the 1304 patients with a diagnosis of SNVs, 40 (3.1%) had digital necrosis and 25 (1.9%) had isolated necrotic cutaneous ulcers, with an equal distribution among SNVs. Presence of cutaneous ischemia was associated with past and/or current smoking [odds ratio (OR), 1.73; 95% confidence interval (95% CI), 1.02-2.95] and history of coronary artery disease (2.40; 1.01-6.00), as well as with other cutaneous manifestations (6.54; 3.21-8.67), gastrointestinal tract perforations (4.29; 1.41-13.07), and arthralgias (1.84; 1.10-3.07) during diagnosis. Ten patients with digital necrosis underwent extremity amputation, but no patient with isolated necrotic cutaneous ulcers (p = 0.007) underwent it. Smoking was the main risk factor of amputation (OR, 9.1; 1.7-48.9). At a mean follow-up of 10 years, cutaneous ischemia was identified as an independent predictor of vasculitis relapse (hazard ratio, 1.47; 95% CI, 1.05-2.05) and all-cause death (1.66; 1.01-2.74). CONCLUSIONS: Cutaneous ischemia is a rare manifestation of SNVs but is associated with an increased risk of relapse and mortality. Tobacco use is associated with amputation, which emphasizes the importance of managing conventional cardiovascular risk factors in SNV patients.

Extensive cutaneous necrosis in a 12-year-old girl: an unusual complication of secondary cold agglutinin syndrome.

Cold agglutinin syndrome (CAS) secondary to infection is rare, usually presenting with anaemia and minor skin changes. A 12-year-old girl with secondary CAS associated with extensive cutaneous necrosis is reported. She presented with fever and multiple necrotic lesions over both cheeks, the tip of nose, ear margins, hands and buttocks, along with pallor, hepatospenomegaly, acrocyanosis and gangrene of the fifth digit of the right hand. She had anaemia, unconjugated hyperbilirubinaemia and a positive direct antiglobulin test owing to cold agglutinins of the IgM type with anti-i specificity and titres of 1:512 at 4°C. Results of bone marrow examination were normal and cryoglobulins were negative. Cold antibodies released even during a brief, self-limited febrile illness can cause widespread cutaneous gangrene. We believe this is the first report in the paediatric age group.

Necrosis cutánea profunda por la aplicación local de hojas de Piper auritum Kunth (caisimón de anís) / Deep cutaneous necrosis caused by the local application of Piper aurifum Kunth (caisimón de anis) leaves

Introducción: Piper auritum Kunth (caisimón de anís) es una de las plantas más utilizadas tradicionalmente en Cuba por sus propiedades antiinflamatorias, analgésicas y cicatrizantes. Objetivos: reportar un caso clínico que sufrió una reacción adversa por automedicación de hojas de Piper auritum. Métodos: se revisó la literatura y la historia clínica de una paciente femenina atendida en el servicio del Hospital Universitario Dr Miguel Enríquez, Servicio de Cirugía Plástica y Caumatología. Resultados: se presentó el caso de una paciente que sufrió lesiones por quemaduras hipodérmicas y sus consecuencias al aplicar hojas de P auritum de forma incorrecta sobre la piel de las mamas, que necesitaron autoinjertos de piel laminar de espesor parcial medio con resultados satisfactorios. Conclusiones: es importante la orientación por personal especializado para el uso de las plantas medicinales(AU)

Introduction: Piper aurifum Kunth (caisimón de anis) is one of the most used plants traditionally in Cuba because of its anti-inflammatory, analgesic and healing properties. Objectives: to report a clinical case suffering from an adverse reaction caused by self-medication with Piper aurifum leaves. Methods: the medical literature and the medical history of a female patient, who was seen at Dr Miguel Enríquez university hospital plastic surgery and burn treatment service, were reviewed. Results: the case of a patient who suffered lesions from hypodermic burns caused by the wrong application of P aurifum leaves on the breast skin was presented. It was necessary to use laminar skin autografts of average partial thickness to cure the lesions, with satisfactory results. Conclusions: it is important that specialists provide appropriate instructions about the use of medicinal plants(AU)