Burkholderia cepacia skin-related ulceration: a case report

Treatment of infected wounds remains a major challenge for clinicians. Antimicrobial stewardship is an important pillar in wound treatment and, as the role of bacteria in wound repair is not well understood, new treatment options and products are constantly being developed to tackle local infection and biofilm. This case report describes a case of antibiotic-resistant Burkholderia cepacia skin infection and subsequent leg ulceration in an 86-year-old man during the COVID pandemic in Italy, which was successfully treated in a conservative way using 1% acetic acid and silver oxysalts in conjunction with compression bandage.

Impact of race and ethnicity on length of stay, discharge location, and total charges for inpatients with skin ulcers in New York

BACKGROUND

Black patients receiving outpatient care for skin ulcers are less likely to see a physician and are at risk for higher stage pressure injuries. While racial/ethnic differences in outpatient treatment of skin ulcers have been described, this study aims to elucidate potential differences in the inpatient setting using publicly available data.

METHODS

We conducted a retrospective cohort study of the Statewide Planning and Research Cooperative System database, a de-identified, patient-level dataset for inpatient visits in New York between 2009 and 2021. Admissions were filtered by diagnosis-related group (APR-DRG) code 380 (skin ulcers).

RESULTS

Compared to non-Hispanic white patients, non-Hispanic black patients demonstrated longer mean LOS (8.15 vs. 7.48 days, p = 0.009), higher mean charges ($44,400 vs. $37,600, p < 0.001), and were more frequently discharged home without services (38.1% vs. 32.4%, p < 0.001). Black Hispanic patients had similar mean LOS (7.22 vs. 6.36 days, p = 0.133), similarly discharged home without services, and had higher mean charges ($45,800 vs. $36,700, p = 0.031). After adjusting for patient factors, non-Hispanic black patients had a longer LOS by 0.26 days (p = 0.028) with $2331 higher inpatient charges (p = 0.001) compared to non-Hispanic white patients.

CONCLUSIONS

The findings suggest racial and ethnic differences in hospitalizations for skin ulcers, with black patients experiencing greater LOS and charges. The reasons for these differences merit investigation, yet could be related to delays in outpatient care, more severe disease, presence of comorbid conditions, or complications requiring intensive inpatient services.

Chronic skin ulcers in hemodialysis patient: A fatal case of calciphylaxis

Calciphylaxis is a rare and deadly vascular disease with poorly understood pathophysiology and without definitive treatment. Early presentations include skin ulcers with risk factors including end stage renal disease on hemodialysis, hypertension, hyperlipidemia, and diabetes mellitus. In our case, we present an 80-year-old female with multiple risk factors including hemodialysis and clinical features of necrotic and gangrenous skin lesions diagnostic of calciphylaxis who became hemodynamically unstable and ultimately expired secondary to toxic sequelae. We illustrate this case to explore early clinical presentation, limitations of current disease management and treatments, and the role for further studies to improve diagnosis and reduce mortality.

The Role of Systemic and Topical Beta-Blockers in Dermatology: A Systematic Review

INTRODUCTION

Beta-blockers are proven to be safe and cost-effective agents in treating multiple dermatological conditions, which is why they are considered as an interesting and good alternative therapeutic agent by dermatologists. To our knowledge, there has been no comprehensive systematic review to date summarizing the role of both systemic and topical beta-blockers in dermatology.

METHODS

In this systematic review, we aim to review recent and relevant published literature in order to provide a comprehensive evidence-based summary to inform dermatologists.

RESULTS

An electronic-based literature search was carried out during October-December 2021 in the databases PubMed (MEDLINE), SCOPUS (EMBASE), and Cochrane Library. Furthermore, bibliographic sources were also reviewed for the selected articles. We followed The Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 (PRISMA) guidelines. We reviewed published literature about the role of beta-blockers in dermatology for the time period (January 2016 to December 2021).

CONCLUSIONS

A total of 126 publications were retrieved from different databases, of which 59 studies were finally included in our review after excluding non-eligible literature in accordance with our inclusion and exclusion criteria. The included articles consisted of meta-analyses, systematic reviews, clinical trials, retrospective and prospective cohort studies, case-control studies, case series, and case reports. In general, data in reviewed literature showed that both systemic and topical beta-blockers were reliable and safe therapeutic options in treating different dermatoses. Their effect has been studied as a mono-therapy, also as an adjuvant therapy combined with other current disease-specific therapeutic modalities such as lasers, radiation, chemotherapy, corticosteroids, or other beta-blockers options. Local and systemic adverse effects were mainly minor and non-significant.

Photobiomodulation Therapy: A New Light in the Treatment of Systemic Sclerosis Skin Ulcers

INTRODUCTION

Skin ulcers (SU) represent one of the most frequent manifestations of systemic sclerosis (SSc), occurring in almost 50% of scleroderma patients. SSc-SU are often particularly difficult to treat with conventional systemic and local therapies. In this study, a preliminary evaluation of the role and effectiveness of blue light photobiomodulation (PBM) therapy with EmoLED^® in the treatment of scleroderma skin ulcers (SSc-SU) was performed.

METHODS

We retrospectively analyzed 12 consecutive SSc patients with a total of 15 SU on finger hands. All patients were treated with adequate systemic therapy and local treatment for SU; after a standard skin ulcer bed preparation with debridement of all lesions, EmoLED^® was performed. All patients were locally treated every week during 2 months of follow-up; SU data were collected after 4 weeks (T4) and 8 weeks (T8). Eight SSc patients with comparable SU were also evaluated as controls.

RESULTS

The application of EmoLED^® in addition to debridement apparently produced faster healing of SU. Complete healing of SU was recorded in 41.6% cases during EmoLED^® treatment. Significant improvements in SU area, length, and width, wound bed, and related pain were observed in EmoLED^® patients from T0 to T8. Control subjects treated with standard systemic/local therapies merely showed an amelioration of SU area and width at the end of the follow-up. No procedural or post-procedural adverse events were reported.

CONCLUSIONS

The positive clinical results and the absence of side effects suggest that EmoLED^® could be a promising tool in the management of SSc-SU, with an interesting role to play in the healing process in addition to conventional systemic and local treatments.

Skin ulcers caused by ruxolitinib in a patient with chronic cutaneous graft-versus-host disease

INTRODUCTION

Graft-versus-host disease (GVHD) is a common complication of allogeneic hematopoietic cell transplantation (HCT). In the treatment of chronic GVHD, skin directed therapy, systemic corticosteroids, calcineurin inhibitors (such as cyclosporine (CsA) and tacrolimus), rituximab, mycophenolate mofetil (MMF), extracorporeal photopheresis (ECP) and ruxolitinib are used.

CASE REPORT

We present an 18 year old male with Philadelphia chromosome positive acute B lymphoblastic leukemia, treated with allogeneic HCT from a full matched sibling donor. The patient had grade 2 chronic cutaneous GVHD resistant to corticosteroids, CsA, MMF, and ECP treatment. Three months after initiation of ruxolitinib therapy, the patient developed skin ulcers on his lower extremities.

MANAGEMENT & OUTCOME

The biopsy revealed that the changes were caused by the drug reactions. We suspected ruxolitinib as the likely cause of these ulcerative lesions after evaluating the adverse drug reaction probability scale. The adverse drug score was 4, therefore, ruxolitinib treatment was discontinued. Ulcerative lesions fully recovered after 4 weeks of follow-up.

DISCUSSION

Ruxolitinib is used in the treatment of chronic GVHD that has been resistant to steroids and other salvage therapies. In our case, ruxolitinib was used as a salvage therapy in a patient who had refractory chronic skin GVHD. Ruxolitinib-related skin lesions with ulcers of lower extremities and whole body erythematous skin lesions were reported previously in patients with myelofibrosis. The pathophysiology of ruxolitinib related skin ulcers is unknown. Skin changes of patients using ruxolitinib should be closely monitored, and newly developing lesions should be suspected of being drug-related and biopsied.

Management of Non-criteria Manifestations in Antiphospholipid Syndrome

PURPOSE OF THE REVIEW

To review the available evidence on the management of a variety of non-criteria manifestations in antiphospholipid syndrome (APS), including valvular disease, alveolar hemorrhage, thrombocytopenia, hemolytic anemia, APS nephropathy, skin ulcers, livedo reticularis, cognitive dysfunction, and epilepsy.

RECENT FINDINGS

Current treatment relies on low-level evidence and mainly on expert consensus due to the rarity and the heterogeneity of non-criteria APS manifestations and the diversity in management approaches. Conventional anticoagulation and/or antiplatelet APS treatment do not adequately control most of non-criteria manifestations. Increasing knowledge about the contribution of inflammatory in addition to, or independently of, thrombotic mechanisms in non-criteria APS manifestations provides insight into the potential effect of novel therapies targeting B-cells, mammalian target of rapamycin, neutrophil, and complement or interferon pathways. Existing evidence is limited by lack of high-quality studies. Better understanding of the pathophysiology and clinical phenotypes of APS and well-designed prospective studies of homogenous populations are needed to provide evidence-based recommendations for the management of non-criteria APS manifestations.

Effect of Cord Blood Platelet Gel on wound healing capacity of human Mesenchymal Stromal Cells

BACKGROUND

Wound healing is a dynamic process, involving the recruitment of growth factors, cytokines, chemokines and cellular populations. Recently, the Cord Blood Platelet Gel (CBPG) has been applied successfully in wound closure and tissue regeneration. Moreover, its proper combination with stem cell populations such as Mesenchymal Stromal Cells (MSCs) may positively improve the wound healing process. Based on the above data, this study aimed to the evaluation of wound healing capacity of MSCs combined with CBPG under in vitro conditions.

METHODS

Initially, CBPG was developed from Cord Blood Units (CBUs). The determination of wound healing ability of MSCs was performed using the scratch wound assay. In addition, the morphological features, immunophenotypical characteristics and differentiation capacity of MSCs were evaluated.

RESULTS

Scratch wound assay results showed, that CBPG could positively stimulate the MSCs migration. Moreover, MSCs cultured in presence of CBPG were characterized by elongated shape and improved stemness properties as it was indicated by flow cytometric analysis and differentiation process.

CONCLUSION

These results clearly showed the beneficial effect of CBPG in combination with MSCs in wound healing. The proper combination of CBPG with stem cells strategy may enhance the healing process in patients with skin erosions.

Scleroderma skin ulcers definition, classification and treatment strategies our experience and review of the literature

BACKGROUND

Skin ulcers (SU) are one of the most frequent manifestations of systemic sclerosis (SSc). SSc-SU are very painful, often persistent and recurrent; they may lead to marked impairment of patient's activities and quality of life. Despite their severe impact on the whole SSc patient's management, the proposed definition, classification criteria, and therapeutic strategies of SSc-SU are still controversial.

OBJECTIVE

The present study aimed to elaborate a comprehensive proposal of definition, classification, and therapeutic strategy of SSc-SU on the basis of our long-term single center experience along with a careful revision of the world literature on the same topic.

METHODS

A series of 282 SSc patients (254 females and 28 males; 84% with limited and 16% diffuse cutaneous SSc; mean age of 51.5±13.9SD at SSc onset; mean follow-up 5.8±4.6SDyears) enrolled during the last decade at our Rheumatology Unit were retrospectively evaluated with specific attention to SSc-SU. The SSc-SU were classified in 5 subtypes according to prominent pathogenetic mechanism(s) and localization, namely 1. digital ulcers (DU) of the hands or feet, 2. SU on bony prominence, 3. SU on calcinosis, 4. SU of lower limbs, and 5. DU presenting with gangrene. This latter is a very harmful evolution of both DU of the hands and feet needing a differential diagnosis with critical limb ischemia.

RESULTS

During the follow up period, one or more episodes of SSc-SU were recorded in over half patients (156/282, 55%); skin lesions were often recurrent and difficult-to-heal because of local complications, mainly infections (67.3%), in some cases associated to osteomyelitis (19.2%), gangrene (16%), and/or amputation (11.5%). SSc-SU were significantly associated with lower patients' mean age at the disease onset (p=0.024), male gender (p=0.03), diffuse cutaneous subset (p=0.015), calcinosis (p=0.002), telangiectasia (p=0.008), melanodermia (p<0.001), abnormal PAPs (p=0.036), and/or altered inflammation reactant (CRP, p=0.001). Therapeutic strategy of SSc-SU included both systemic and local pharmacological treatments with particular attention to complicating infections and chronic/procedural pain, as well as a number of non-pharmacological measures. Integrated local treatments were often decisive for the SSc-SU healing; they were mainly based on the wound bed preparation principles that are summarized in the acronym TIME (necrotic Tissue, Infection/Inflammation, Moisture balance, and Epithelization). The updated review of the literature focusing on this challenging issue was analyzed in comparison with our experience.

CONCLUSIONS

The recent advancement of knowledge and management strategies of SSc-SU achieved during the last years lead to the clear-cut improvement of patients' quality of life and reduced long-term disability.

Clinical disorders responsible for plasma hyperviscosity and skin complications

In this brief review, we have examined some clinical disorders which are associated to an altered hemorheological profile and at times accompanied by skin ulcers. This skin condition may be, in fact, observed in patients with primary plasma hyperviscosity such as multiple myeloma, Waldenstrom macroglobulinemia, cryoglobulinemia, cryofibrinogenemia, dysfibrinogenemia and connective tissue diseases. It must be underlined that the altered hemorheological pattern is not the only responsible for this skin complication but, as it worsens the microcirculatory flow, it contributes to determine the occurrence of the skin ulcers.

First isolation of Miamiensis avidus (Ciliophora: Scuticociliatida) associated with skin ulcers from reared pharaoh cuttlefish Sepia pharaonis

In the winter of 2015, a skin ulcer disease outbreak occurred in a pharaoh cuttlefish Sepia pharaonis population cultured on a land-based fish farm in China. Affected cuttlefish (about 60% of the population) were characterized as having developed ulcers on the dorsal skin, fin fringe, or distal mantle tip. Masses of a ciliated protozoan were isolated from skin ulcers. The ciliate was identified as Miamiensis avidus based on the morphological features of living and protargol-impregnated specimens. This identification was also supported by high sequence similarity of the small subunit ribosomal RNA gene (100%) and another ribosomal DNA region (including the 2 internal transcribed spacers and the 5.8S gene; 99%) with published sequences of fish parasitic M. avidus strains. M. avidus is known to be a histophagous marine fish parasite. This report describes the first case of M. avidus associated with skin ulcers in a cephalopod mollusk (Mollusca, Cephalopoda). This finding suggests that M. avidus may infect a phylogenetically broader range of hosts than what has previously been reported. Furthermore, M. avidus may pose a health risk to hatchery-reared cephalopods.

Innovate combination of sevoflurane dilution in dimethyl sulfoxide: A stability study by gas chromatography and nuclear magnetic resonance

AIM

To investigate physicochemical stability of sevoflurane in dimethyl sulfoxide using gas chromatography with a flame ionization detector and nuclear magnetic resonance (NMR).

METHODS

Undiluted sevoflurane, plus dilutions 1:2, 1:5, 1:10, 1:25, and 1:50 in dimethyl sulfoxide were prepared in a vertical laminar flow cabinet class II type B and stored at different temperatures (23 °C, 6 °C, and -10 °C) for 45 d. Sterile 1 mL polypropylene amber syringes to minimize light degradation, caps and needles were used. The presence of sevoflurane and its degradation products in the samples was determined by gas chromatography with flame ionization detector (260 °C, 40 min), and by ¹H, ¹⁹F, and proton-decoupled ¹⁹F nuclear magnetic resonance.

RESULTS

The gas chromatography analysis showed sevoflurane and dimethyl sulfoxide (DMSO) retention times were 2.7 and 13.0 min, respectively. Pure DMSO injection into the column resulted in two additional peaks at 2.1 and 2.8 min. The same sevoflurane peak at 2.7 min was observed in all the dilutions at -10 °C, 4 °C and 25 °C. The NMR spectra showed signals consistent with the sevoflurane structure in all the dilutions at -10 °C, 4 °C and 25 °C. In the ¹H spectrum, two signals corresponding to the sevoflurane molecule were observed at 5.12 and 4.16 parts per million (ppm). In the ¹⁹F-NMR spectrum, two signals were observed at chemical shift -76.77 ppm and chemical shift -157.13 ppm. In the ¹⁹F{¹H}-NMR CPD, two signals were observed at chemical shift -76.77 ppm and chemical shift -157.13 ppm. The first one showed a doublet (J^F-F = 3.1 Hz) which integrated by six fluorine nuclei from the hexafluoro-isopropyl group. The second signal was integrated by a fluorine atom and showed a septuplet (J^F-F = 3.1 Hz).

CONCLUSION

This study shows that different concentrations of sevoflurane in dimethyl sulfoxide retain their chemical composition after exposure to different temperatures for a period of 45 d.

Chronic oozing skin lesions in children: Possible tuberculosis? Two case reports

Cutaneous tuberculosis is frequently misleading and challenging, as it mimics a wide differential diagnosis. Here, we present two pediatric cases with chronic multiple ulcerating nodules. Proper history, physical examination, and histopathological analysis are included in the workup of suspected skin tuberculosis. Diagnosis was confirmed by positive culture for mycobacteria.

Red and infrared laser therapy inhibits in vitro growth of major bacterial species that commonly colonize skin ulcers

Low-level laser therapy (LLLT) is used in chronic wounds due to its healing effects. However, bacterial species may colonize these wounds and the optimal parameters for effective bacterial inhibition are not clear. The aim of this study was to analyze the effect of LLLT on bacterial growth in vitro. Bacterial strains including Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa were suspended in saline solution at a concentration of 10(3) cells/ml and exposed to laser irradiation at wavelengths of 660, 830, and 904 nm at fluences of 0 (control), 3, 6, 12, 18, and 24 J/cm(2). An aliquot of the irradiated suspension was spread on the surface of petri plates and incubated at 37 °C for quantification of colony-forming unit after 24, 48, and 72 h. Laser irradiation inhibited the growth of S. aureus at all wavelengths and fluences higher than 12 J/cm(2), showing a strong correlation between increase in fluence and bacterial inhibition. However, for P. aeruginosa, LLLT inhibited growth at all wavelengths only at a fluence of 24 J/cm(2). E. coli had similar growth inhibition at a wavelength of 830 nm at fluences of 3, 6, 12, and 24 J/cm(2). At wavelengths of 660 and 904 nm, growth inhibition was only observed at fluences of 12 and 18 J/cm(2), respectively. LLLT inhibited bacterial growth at all wavelengths, for a maximum of 72 h after irradiation, indicating a correlation between bacterial species, fluence, and wavelength.

Systemic sclerosis evolution of disease pathomorphosis and survival. Our experience on Italian patients' population and review of the literature

The clinical spectrum and prognosis of systemic sclerosis (SSc) seem to vary among patients' populations recruited during different time periods. In order to verify this possible evolution we investigated the clinico-serological and survival rate in a large Italian SSc series (821 patients; 746 females, 75 males; mean age 53.7±13.9SD years) recruited between 2000 and 2011. The observed findings were compared with previous studies of the world literature.Compared to older Italian SSc series, the present patients' population showed a significantly increased prevalence of limited cutaneous SSc (from 72 to 87.5%; p ≤.0001) and serum anti-centromere antibodies (from 39 to 47,4%; p ≤.001), with a significant reduction of lung (from 81 to 63.7%; p ≤.0001), heart (from 35 to 20.5%; p ≤.0001), and renal involvement (from 10 to 3.8%; p ≤.0001), and skin ulcers (from 54 to 16.5%; p ≤.0001). Cumulative 10th-year survival showed a clear-cut increase (80.7%) compared to our previous series (69.2%). These findings were mirrored by the results of survival studies published during the last five decades, grouped according to the time periods of patients'' recruitment at the referral centers. A clear progression of 10th-year survival rates was detectable, from the 54% median survival of the oldest studies (1935-1974) to 74% and 83.5% of the more recent SSc series, 1976-1999 and after 1999, respectively. In conclusion, the favorable evolution of SSc pathomorphosis and prognosis during the last decades might be related to more diffuse physician/patient awareness of this harmful disease and availability of diagnostic tools, the consequent wider recruitment of patients in the early stages of the disease, as well as to the improved therapeutic strategies.

Calcium alginate particles for the combined delivery of platelet lysate and vancomycin hydrochloride in chronic skin ulcers

The aim of the present work was the development of a powder formulation for the combined delivery of platelet lysate and of a model antibiotic drug, vancomycin hydrochloride (VCM), in chronic skin ulcers. Calcium alginate particles were prepared by freeze-drying beads obtained by ionic gelation method. The experimental conditions adopted permitted the complete loading of VCM and of PDGF AB, the growth factor chosen as representative of those contained in PL. Such particles where able to absorb PBS (mimicking wound exudate), to form a gel and to modulate the release of VCM and of PDGF AB. They are characterized by enhancement properties of human fibroblast proliferation due to PL presence. In particular, PL, when loaded in alginate particles, was able not only to increase the number of viable cells, but also the number of cells in proliferative phase. Such properties were comparable to those of fresh PL indicating the capability of calcium alginate particles to load PL bioactive substances without altering their activity. The formulation developed is characterized by an easier and a less painful administration with respect to traditional gauzes and semisolid preparations and permits the loading in the same dosage form of active substances of different nature avoiding eventual incompatibility problems.