Diagnostic accuracy of ultrasound signs for detecting adnexal torsion: systematic review and meta-analysis.

OBJECTIVE: To evaluate the diagnostic accuracy of different ultrasound signs for diagnosing adnexal torsion, using surgery as the reference standard. METHODS: This was a systematic review and meta-analysis of studies published between January 1990 and November 2021 evaluating ovarian edema, adnexal mass, ovarian Doppler flow findings, the whirlpool sign and pelvic fluid as ultrasound signs (index tests) for detecting adnexal torsion, using surgical findings as the reference standard. The search for studies was performed in PubMed/MEDLINE, CINAHL, Scopus, The Cochrane Library, ClinicalTrials.gov and Web of Science databases. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool was used to evaluate the quality of the studies. Pooled sensitivity, specificity, and positive and negative likelihood ratios were calculated separately, and the post-test probability of adnexal torsion following a positive or negative test was also determined. RESULTS: The search identified 1267 citations after excluding duplicates. Eighteen studies were ultimately included in the qualitative and quantitative syntheses. Eight studies (809 patients) analyzed the presence of ovarian edema, eight studies (1044 patients) analyzed the presence of an adnexal mass, 14 studies (1742 patients) analyzed ovarian Doppler flow, six studies (545 patients) analyzed the whirlpool sign and seven studies (981 patients) analyzed the presence of pelvic fluid as ultrasound signs of adnexal torsion. Overall, the quality of most studies was considered to be moderate or good. However, there was a high risk of bias in the patient-selection and index-text domains (with the exception of the whirlpool sign) in a significant proportion of studies. Pooled sensitivity, specificity, and positive and negative likelihood ratios of each ultrasound sign were 58%, 86%, 4.0 and 0.49 for ovarian edema, 69%, 46%, 1.3 and 0.67 for adnexal mass, 65%, 91%, 7.6 and 0.38 for the whirlpool sign, 53%, 95%, 11.0 and 0.49 for ovarian Doppler findings and 55%, 69%, 1.7 and 0.66 for pelvic fluid. Heterogeneity was high for all analyses. CONCLUSIONS: The presence of an adnexal mass or pelvic fluid have poor diagnostic accuracy as ultrasound signs of adnexal torsion, while the presence of ovarian edema, the whirlpool sign and decreased or absent ovarian Doppler flow have good specificity but moderate sensitivity for detecting adnexal torsion. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Valorization of date palm (Phoenix dactylifera L.) pruning biomass by co-composting with urban and agri-food sludge.

In the Mediterranean countries, there is an increasing production of date palm wastes (Phoenix dactylifera L.), not only due to the raising production of date palm fruits, but also derived from the maintenance of urban and peri-urban green areas, especially in those affected by red palm weevil (Rhynchophorus ferrugineus). The management of this increasing volume of green wastes usually concludes with a controlled disposal that implies an important loss of resources, in terms of organic matter, nutrients and energy. In addition, the rise of wastewater generation and the incentive of the wastewater treatment processes have derived in an increase of the amount of the sludge produced, which makes difficult its management. This work studies the feasibility of co-composting palm wastes with sludge from the urban and agri-food sectors as alternative treatment to manage these organic waste streams and to obtain added-value compost. For this, four mixtures (P1, P2, P3 and P4) were prepared using as main component palm leave waste (PL) mixed with different types of sludge. In the piles P1, P2 and P3, sewage sludge (SS) was used as co-composting agent, while agri-food sludge (AS) was used in P4. Throughout composting, the thermal profile of the composting piles was assessed, as were physical, chemical, physico-chemical and maturity parameters. In addition, the changes in water-soluble organic matter were assessed using chemical analytical methods and the excitation-emission matrix (EEM) fluorescence spectroscopy. The results obtained showed the viability of the co-composting process to obtain end-products with adequate maturity degree and physical characteristics for their potential use as substrates, except for the salt contents that can limit their use in some agricultural sectors.

[Diagnosis and management in pediatric patients with ovarian masses]. / Diagnóstico y manejo de masas ováricas en pacientes pediátricas.

OBJECTIVE: Review of the diagnosis and management of ovarian masses in children, through the identification of preoperative risk factors of malignancy, the evaluation of surgical management and its results. METHODS: Retrospective study in pediatric patients under 18 years old, managed surgically by ovarian masses. Analyzed data were symptoms, imagining, tumor markers, treatment, outcomes and pathology. The primary endpoint was ovarian malignancy. RESULTS: We identified 54 patients with ovarian masses between 2014 and 2017, of which 49 were benign and 5 malignant; The malignant ovarian masses were significantly larger than the benign, with an average of 19.4 cm vs 6.49 cm (p = 0.0001); had greater solid component in the imaging and positive tumor markers (p = 0.001) and were treated with oophorectomy plus tumor staging surgery. Forty-three patients with benign tumors underwent ovarian preservation surgery. The postoperative follow-up of all the patients was on average 3.4 months (1-25 months) and 20.3% presented pelvic pain associated with alterations of the menstrual cycle in their postoperative control. There are no reports of recurrence or contralateral ovarian tumor. CONCLUSIONS: Large masses with solid components and positive tumor markers were significant predictors of malignancy. Minimally invasive ovarian preserving surgery should be considered as the first treatment option in masses with low risk of malignancy. On the other hand, oophorectomy plus tumor staging surgery should be considered for ovarian tumors with a high risk of malignancy.

OBJETIVO: Revisión del diagnóstico y manejo de las masas ováricas en población infantil, mediante la identificación de factores de riesgo preoperatorios de malignidad, la evaluación del manejo quirúrgico y sus resultados. METODOS: Estudio retrospectivo en pacientes pediátricas menores de 18 años, intervenidas quirúrgicamente por masas ováricas. Se analizaron datos como síntomas, imágenes diagnósticas, marcadores tumorales, tratamiento, resultados y patología. La variable principal fue malignidad ovárica. RESULTADOS: Se identificaron 54 pacientes con masas ováricas entre el año 2014 a 2017, de las cuales 49 fueron benignas y 5 malignas. Las masas ováricas malignas fueron significativamente más grandes que las benignas, con media de 19,4 cm vs 6,49 cm (p = 0,0001); tuvieron mayor componente sólido en los hallazgos imagenológicos y marcadores tumorales positivos (p = 0,001) y fueron tratadas con ooforectomía más cirugía de estadificación tumoral. A 43 pacientes con tumores benignos se les realizó cirugía preservadora de ovario. El seguimiento postoperatorio de todas las pacientes fue en promedio de 3,4 meses (1-25 meses) y el 20,3% presentaron dolor pélvico asociado a alteraciones del ciclo menstrual en su control postoperatorio. No hay reportes de recidiva ni tumor de ovario contralateral. CONCLUSIONES: Masas grandes, con componentes sólidos y marcadores tumorales positivos fueron predictores significativos de malignidad. La cirugía preservadora de ovario por vía mínimamente invasiva debe ser considerada como primera opción de tratamiento en masas con bajo riesgo de malignidad; Por otra parte, la ooforectomía más cirugía de estadificación tumoral, debe ser considerada para los tumores ováricos con alto riesgo de malignidad.

Nailfold capillaroscopy in diabetes mellitus.

INTRODUCTION: Diabetes mellitus (DM) is characterized by chronic hyperglycemia states and the development of specific microvascular disorders such as retinopathy and nephropathy. Conventional methods are used to study the vascular compromise of this entity, however, the use of capillaroscopy for the evaluation of capillary microarchitecture is not frequently used. METHODS AND MATERIALS: Observational and descriptive study of 65 patients with an established diagnosis of DM and a control group that underwent an initial capillaroscopy examination. The parameters considered were: Capillary diameter (ectasia and giant capillaries), cross-linked, tortuous, arborified capillaries, avascular zones, haemorrhages, dominant morphology, visibility of the subpapillary venous plexus (SPVP), cuticulitis and SD pattern. RESULTS: Capillaroscopy was performed in 65 patients, the findings were: tortous capillaries (63%), crosslinked capillaries (59%), avascular areas (48%), ectasias (39%), giant capillaries (11%). The capillaroscopic findings were evident in the majority of the studied population, 83%, compared to 17% who did not have capillaroscopic alterations. CONCLUSION: Significant capillaroscopic changes were demonstrated in patients with DM, in turn, we described a specific pattern consisting of: capillary dilatation, avascular zones and tortuous capillaries. Patients with more comorbidities and evolution of the disease showed greater microvascular damage.

Determination of Vitamin D Status in a Population of Ecuadorian Subjects.

INTRODUCTION: Vitamin D is a preprohormone known to play a key role in phosphocalcic metabolism; its main source comes from the synthesis at the skin level by ultraviolet (UV) radiation. OBJECTIVE: The purpose of this study was to determine the levels of vitamin D in an Ecuadorian population. MATERIALS AND METHODS: Retrospective study of Ecuadorian subjects from the city of Guayaquil, who had an initial study of 25 (OH)-D serum, as the indicator of Vitamin D status, in the period of 2015-2016. RESULTS: A total of 269 Ecuadorian subjects were analyzed, with a mean age of 54.73 ± 16.58; 85% (229) were females and 15% (41) males; mean vitamin D was 27.29 ± 10.12 ng/dl [6.41-88.74]; 70% of the population showed levels below 30 ng/dL of vitamin D, whereas only 30% (81) had normal values. 69% (185) had levels between 29 and 10 ng/dl and 1% (3) levels below 10 ng/dl. High levels of vitamin D were evidenced in the summer months in relation to the winter months. CONCLUSION: It is evident that, despite the location of Ecuador and the intensity of UV rays it receives throughout the year, Ecuadorian subjects have insufficient levels of vitamin D.

Human gut microbiota analysis of cystic fibrosis infants using metaproteomics.

We report a metaproteomic analysis of the gut microbiota of eight infants with cystic fibrosis, during the first year of life. This is the first study in this disease that uses metaproteomics to analyze stool samples from patients at such a young age.

[Clinical usefulness of biomarkers in cardiac failure]. / Utilidad de los biomarcadores en insuficiencia cardiaca en la práctica clínica.

The assessment of patients with a suspected cardiac failure aims to an early and precise diagnosis and risk stratification. Only natriuretic peptides have demonstrated to be clinically useful. Brain natriuretic peptide stands out due to its diagnostic and prognostic value. However its results should be cautiously interpreted in the clinical context, bearing in mind possible confounders. The combination of markers can provide a better risk stratification and compensates the limitations of individual markers. Each new marker gives a new insight on the underlying physiopathology of cardiac failure and proposes new therapeutic approaches.

Analysis of the influence of variation factors on electrical conductivity of milk in Murciano-Granadina goats.

The aim of this study was to obtain further knowledge on electrical conductivity (EC) of milk as a tool for detecting mastitis in goats. The effect of farm, parity, stage of lactation, and health status of the glands on EC, and the somatic cell count (SCC) of milk was analyzed. Additionally, relationships between EC and chemical composition and SCC were studied. Finally, characteristics of EC and SCC (sensitivity and specificity) as diagnostic tests used to detect mastitis were studied. One hundred and five Murciano-Granadina goats were enrolled in the study. Milk samples (by gland) were collected monthly for 7 mo on 3 farms in the southeastern Spain. To establish the health status, milk samples were aseptically collected before milking by gland. Foremilk (by gland) was collected to analyze EC, SCC, and chemical composition. Glands were classified according to the health status as free of mastitis, bacterial mastitis, or unspecific mastitis. The effects of farm, parity, and stage of lactation, as well as the interactions between health status and parity, parity and stage of lactation, and health status and stage of lactation were associated with EC. Changes in the milk's chemical composition (particularly of chloride ions) explained most of the variance in EC (R(2)=0.91). The strongest association between EC and SCC was found at SCC >2×10(6) cells/mL (r=0.42). The use of a single EC threshold for all animals and farms for detecting mastitis led to limited results for mastitis detection, which, in any case, favors negative predictive values over positive predictive values. This study revealed that factors, other than the health status, affecting EC hamper the use of an EC threshold for mastitis detection with sufficient specificity on all animals. Any detection system based on EC of milk should consider these factors, as well as specific variations for each of the animals.

Rethinking interleukin-6 blockade for treatment of COVID-19.

Interleukin-6 (IL-6) is a pleiotropic cytokine with effects in immune regulation, inflammation, and infection. The use of drugs that inhibit IL-6 biological activity has been proposed as a treatment for patients with Coronavirus Disease 2019 (COVID-19). The rationale for this approach includes commitment to the concept that inflammation is a cause of lung damage in COVID-19 and belief that IL-6 is a pro-inflammatory molecule. Observational data thought to support IL-6 inhibition include elevated circulating IL-6 levels in COVID-19 patients and association between elevated IL-6 and poor clinical outcomes. However, IL-6 has significant anti-inflammatory properties, which calls into question the rationale for employing IL-6 blockade to suppress inflammation-induced tissue injury. Also, studies suggesting a beneficial role for IL-6 in the host response to infection challenge the strategy of using IL-6 blockade to treat COVID-19. In studies of recombinant IL-6 injected into human volunteers, IL-6 levels exceeding those measured in COVID-19 patients have been observed with no pulmonary adverse events or other organ damage. These observations question the role of IL-6 as a contributing factor in COVID-19. Clinical experience with IL-6 receptor antagonists such as tocilizumab demonstrates increase in severe and opportunistic infections, raising concern about using tocilizumab and similar agents to treat COVID-19. Trials of drugs to inhibit IL-6 activity in COVID-19 are ongoing and will shed light on the role of IL-6 in COVID-19 pathogenesis. However, until more information is available, providers should exercise caution in prescribing these therapies given the potential for patient harm.

Cholelithiasis and associated complications in pediatric patients. / Colelitiasis y complicaciones asociadas en pacientes pediátricos.

OBJECTIVE: To review the clinical characteristics and complications associated with cholelithiasis in pediatric patients by identifying risk factors and assessing surgical management and results. METHODS: Retrospective study in patients under 18 years of age undergoing cholelithiasis surgery. The following data were analyzed: age, sex, body mass index (BMI), associated comorbidities, clinical presentation, symptom duration, surgical treatment, pathological report, postoperative complications, and hospital stay. RESULTS: 135 cholelithiasis patients underwent surgery from 2013 to 2018, with an increasing trend in the annual number of cholecystectomies. Most patients were adolescents (86.7%) and female (72.6%), and they had cholesterol gallstones (86.6%) and >85 BMI (33%). Mean symptom duration was 85 days (SD: 148). Symptomatic cholelithiasis was present in 131 cases (97%). CL associated complications were recorded in 64.4% of patients, with cholecystitis, pancreatitis, and choledocholithiasis being the most frequent ones. All patients underwent laparoscopic cholecystectomy; 4 (2.9%) required conversion to open surgery, and 6 (4.4%) had postoperative complications. Mean hospital stay and postoperative follow-up were 5.7 days (SD: 4) and 2.3 months (SD: 1.9), respectively. CONCLUSIONS: Non-hemolytic cholelithiasis in the pediatric population is more frequent in female overweight and obese adolescents. Symptomatic cholelithiasis is associated with higher risk of complications such as cholecystitis, pancreatitis, or choledocholithiasis, which supports early surgical management.

OBJETIVO: Revisión de las características clínicas y complicaciones asociadas de los pacientes pediátricos con colelitiasis, mediante la identificación de factores de riesgo, la evaluación del manejo quirúrgico y sus resultados. METODOS: Estudio retrospectivo en pacientes menores de 18 años, intervenidos quirúrgicamente por colelitiasis. Se analizaron datos como edad, género, índice de masa corporal (IMC), comorbilidades asociadas, presentación clínica, tiempo de los síntomas, tratamiento quirúrgico, reporte de patología, complicaciones posoperatorias y estancia hospitalaria. RESULTADOS: Se intervinieron quirúrgicamente 135 pacientes con colelitiasis entre los años 2013 a 2018, con una tendencia ascendente en el número de colecistectomías realizadas anualmente. La mayoría fueron pacientes adolescentes (86,7%), con cálculos de colesterol (86,6%), de género femenino (72,6%) y con IMC > 85 (33%). El tiempo de los síntomas en promedio fue de 85 días (DE 148). Colelitiasis sintomática se presentó en 131 casos (97%). Complicaciones asociadas a CL se registraron en 64,4% pacientes, siendo las más frecuentes colecistitis, pancreatitis y coledocolitiasis. En todos los pacientes se realizó colecistectomía laparoscópica, 4 (2,9%) requirieron conversión a cirugía abierta y 6 (4,4%) presentaron complicaciones postoperatorias. La estancia hospitalaria y el seguimiento posoperatorio fueron en promedio 5,7 días (DE 4) y 2,3 meses (DE 1,9), respectivamentea. CONCLUSIONES: La colelitiasis no hemolítica en la población pediátrica, es más frecuente en pacientes adolescentes de género femenino con sobrepeso u obesidad. La colelitiasis sintomática está asociada con mayor riesgo de complicaciones como colecistitis, pancreatitis o coledocolitiasis, en consecuencia, se justifica una intervención quirúrgica temprana.

Case Report: Cutaneous Leishmaniasis due to Leishmania (Viannia) panamensis in Two Travelers Successfully Treated with Miltefosine.

We present two cases of Leishmania (V) panamensis in returning travelers from Central America successfully treated with miltefosine. The couple presented with ulcerative skin lesions nonresponsive to antibiotics. Skin biopsy with polymerase chain reaction (PCR) revealed L. (V) panamensis. To prevent the development of mucosal disease and avoid the inconvenience of parental therapy, we treated both patients with oral miltefosine. We suggest that miltefosine represents an important therapeutic alternative in the treatment of cutaneous lesions caused by L. panamensis and in preventing mucosal involvement.

A rare opportunistic infection in a woman with systemic lupus erythematosus and multiple skin lesions.

Cutaneous lesions in patients with systemic lupus erythematosus (SLE) represent diagnostic challenges. Opportunistic infections should be considered when lupus patients are on immunosuppressive therapy and other causes, such as disease activity, are less likely to explain the skin lesions. Within the spectrum of skin opportunistic infections that might occur in SLE patients, Blastomyces dermatitidis should be suspected when acid-fast positive material with no bacilliform organisms is seen on Ziehl-Nielsen skin biopsy preparations. In this study, we describe one patient with SLE on immunosuppressive therapy, who developed cutaneous blastomycosis despite living in a non-endemic area. Because of lack of awareness about this association and misinterpretation of the skin biopsy results, the diagnosis of atypical mycobacterial infection was initially considered. Subsequent proper tissue staining and interpretation revealed the correct diagnosis of disseminated cutaneous blastomycosis. This description represents the first report of this rare opportunistic skin infection in SLE, illustrating the importance of performing correct preparation and elucidation of the skin biopsy to avoid misdiagnosis and treatment delay.

Evolution of the pathogen content during co-composting of winery and distillery wastes.

The aim of this study was to monitor some microbial indicators and pathogen contents (sulphite reducers clostridia, total enterobacteriaceae, total coliforms, faecal coliforms (Escherichia coli), enterococci, Staphylococcus aureus and Salmonella spp.) throughout the co-composting of wastes from the winery and distillery industry with other organic residues, as well as the effect of the composting system used. Seven different piles using mixtures of winery-distillery wastes with other organic materials were prepared. P1 and P2 were made using grape stalk (GS), grape marc (GM), exhausted grape marc (EGM) and sewage sludge (SS), whereas in P3 and P4 were also used exhausted grape marc with cow manure (CW) and poultry manure (PM), respectively, using the Rutgers system. Additionally, P2 was watered with vinasse (V). The rest of piles (P5, P6 and P7) were prepared with grape marc, exhausted grape marc, cow manure and poultry manure, using the turning system. The effectiveness of the composting process to reduce the pathogen content was higher in the static aerated piles than in those elaborated with the turning. The relatively high temperatures (50-60 degrees C) reached in some of the piles produced a notable decrease in some microbial groups, such as total and faecal coliforms (E. coli), but the characteristics of the raw materials used notably influenced the pathogen contents of the end-product.

Co-composting of distillery wastes with animal manures: carbon and nitrogen transformations in the evaluation of compost stability.

The aim of this work was to study the viability of recycling the solid wastes generated by the winery and distillery industry by means of co-composting with animal manures, as well as to evaluate the quality of the composts obtained. Two piles, using exhausted grape marc and cattle manure or poultry manure, respectively (at ratios, on a fresh weight basis, of 70:30), were composted by the Rutgers static pile composting system. Throughout the composting process, a number of parameters were monitored, such as pH, electrical conductivity, organic matter, water-soluble carbon, water-soluble polyphenols, different forms of nitrogen (organic nitrogen, ammonium and nitrate) and humification indices (humification ratio, humification index, percentage of humic acid-like C, polymerisation ratio and cation exchange capacity), as well as the germination index. Organic matter losses followed first-order kinetics equation in both piles, the highest organic matter mineralisation rate being observed with exhausted grape marc and cow manure. On the other hand, the mixture with the lowest C/N ratio, using exhausted grape marc and poultry manure, showed the highest initial ammonium contents, probably due to the higher and more labile N content of poultry manure. The increase in the cation exchange capacity revealed the organic matter humification during composting. In contrast, other humification parameters, such as the humification ratio and the humification index, did not show the expected evolution and, thus, could not be used to assess compost maturity. Composting produced a degradation of the phytotoxic compounds, such as polyphenols, to give composts without a phytotoxic character. Therefore, composting can be considered as an efficient treatment to recycle this type of wastes, due to composts presented a stable and humified organic matter and without phytotoxic effects, which makes them suitable for their agronomic use.

Salinity, organic content, micronutrients and heavy metals in pig slurries from South-eastern Spain.

The increase in commercial pig production is an opportunity to reuse animal manures in arid and semiarid soils as a source of nutrients and organic matter. However, there are components in pig slurry that are potentially dangerous for the environment. In this study, pig slurries of 36 pig farms in South-eastern Spain were evaluated for salt content (electrical conductivity, chloride and sodium), organic load (BOD5 and COD), micronutrients (Fe, Cu, Mn and Zn), and heavy metals (Cd, Co, Cr, Ni and Pb). Except for electrical conductivity, Cu and Zn, components in pig slurries did not vary considerably between animal production stages, indicating similar management of diverse animal types. Assuming an application rate based on the maximum input of nitrogen from animal manure (210 kg total N/ha/yr), the estimates for soil annual load of Cl and Na, 415 kg/ha, could be a significant salinisation risk. Cu and Zn seemed to be the metals that could be accumulated most in soils where application of pig slurries is common (4 and 15 kg/ha/yr, respectively). The estimated heavy metal (Cd, Co, Cr, Ni and Pb) input to soils would be 260 g/ha/yr, with a relative contribution of Cr>Ni>Pb>Co>Cd.

Agrochemical characterisation of the solid by-products and residues from the winery and distillery industry.

The winery and distillery industry produces a great quantity of residues, whose management and disposal are environmental problems due to their seasonal character and some polluting characteristics. The main solid by-products and residues generated are grape stalk, grape pomace or marc, wine lee, exhausted grape marc and winery sludge. In this study, 87 samples of winery and distillery residues were collected from different Spanish wineries and distilleries. Electrical conductivity, pH, total organic matter, organic carbon, polyphenols and contents of plant nutrients and heavy metals were determined. The purpose of this research was to study the composition of these wastes and to find relationships in order to use easily analysable parameters to estimate their composition. In general, the winery and distillery residues showed low pH (mean values ranged from 3.8 to 6.8) and electrical conductivity values (1.62-6.15 dS m(-1)) and high organic matter (669-920 g kg(-1)) and macronutrient contents, especially in K (11.9-72.8 g kg(-1)). However, a notable polyphenol concentration (1.2-19.0 g kg(-1)) and low micronutrient and heavy metal contents were also observed, some of these properties being incompatible with agricultural requirements. Therefore, conditioning treatments are necessary prior to possible use of these wastes. In all wastes, significant correlations were found between easily determined parameters, such as pH, electrical conductivity and total organic matter, and most of the parameters studied. The regression models obtained are also discussed.

Cutaneous Manifestations of Mycobacterium kansasii Infection.

Purpose of Review: Mycobacterium kansasii is a slow-growing member of the nontuberculous mycobacterial species that manifests clinically with pulmonary, cutaneous, or disseminated forms. Most cases of M. kansasii infection occur in immunocompromised hosts including HIV/AIDS, solid-organ transplantation, anti-interferon-γ antibody disorder, or among those with pulmonary disorders such as chronic obstructive pulmonary disease or cystic fibrosis. In this review, we aim to discuss relevant literature regarding the clinical manifestations of this infection with a particular emphasis on the clinical spectrum and treatment of the cutaneous manifestations of this mycobacterial infection. Recent Findings: Infection caused by M. kansasii is associated with exposure to contaminated municipal water systems since this organism thrives in human-engineered environments. Chronic or subacute skin lesions may represent the primary source of entry of the organism due to open sores or traumatic injuries. Alternatively, cutaneous lesions may occur secondary to dissemination of the organism to the skin from pulmonary infection. The diagnosis of M. kansasii of the skin and soft tissues should be entertained among immunocompetent or immunocompromised individuals presenting with subacute or chronic lesions. The differential diagnosis of M. kansasii infection includes infections of skin and soft tissues caused by rapidly growing mycobacteria, subcutaneous mycosis, pyogenic bacterial infections, nocardiosis, free-living amoebas, and protothecosis. Summary: Cutaneous lesions caused by M. kansasii most commonly manifest in the setting of concomitant pulmonary disease or in the setting of disseminated infection among immunocompromised hosts. When clinicians suspect a cutaneous mycobacterial infection either due to slow-growing mycobacteria such as M. kansasii or due to rapidly growing mycobacteria, obtaining a skin biopsy of chronic nonhealing lesions for histopathologic evaluation and for microbiological assessment is crucial. Mycobacteriology assessment of clinical specimen includes acid-fast bacilli staining, culture in solid/liquid media, and molecular assays for confirmation. Treatment of M. kansasii infection of the skin and subcutaneous tissues follows the same management recommendations as those for the treatment of isolated pulmonary forms or disseminated disease.