[A woman with nodules on her arm]

A 73 year old female presented with five non-painful nodules on the dorsal side of her right lower arm that occured after an infection on her third digit finger after cleaning her aquarium. PCR of the biopsy from on of the nodules shows a mycobacterium marinum infection.

[An unvaccinated man with a painful arm and jaw]

BACKGROUND

Clostridium tetani is a gram-positive spore-forming bacterium that produces toxins and grows under anaerobic conditions. Infections with this bacterium can lead to local or generalised forms of tetanus.

CASE DESCRIPTION

An 83-year-old man presented to the acute cardiac care unit with a painful left arm and jaw. Because the patient had a hypertonic left arm and was unable to open his mouth fully, the neurologist was consulted. The patient had been to the emergency department 9 days earlier for an infected wound after falling in the garden. He had not been actively or passively immunised against tetanus at that time. On inquiry, it appeared that the patient had also not been vaccinated as a child. We made a clinical diagnosis of tetanus. The patient was admitted and treated with tetanus immunoglobulin, metronidazole, diazepam and painkillers. He was also administered tetanus toxoid and the wound was cleaned. After 1 month and 7 months, the patient was again administered tetanus toxoid.

CONCLUSION

Patients with a wound that may have come into contact with road grime, dirt or manure, should always be asked for their vaccination status, especially people from high-risk groups, such as the elderly.

Ulcerative cellulitis of the arm: a case of primary cutaneous cryptococcosis

Cutaneous cryptococcosis is usually secondary to the hematogenous dissemination of pulmonary or meningeal Cryptococcus neoformans. Primary cutaneous cryptococcosis (PCC) is a rare form of the infection, typically caused by direct inoculation from trauma to the skin [1]. Most cases of PCC present as a localized cellulitis, abscess, nodule, or ulceration. Herein, we present a case of a rapidly spreading cellulitis characterized by bullae and ulceration, caused by direct inoculation from a fall.

Common dermatophytes and in vitro anti-fungal susceptibility testing in patients attending the Dermatological Clinic at the Hospital for Tropical Medicine, Bangkok

Dermatophytes comprising the genera Trichophyton, Microsporum, and Epidermophyton are important causes of superficial mycoses. The number of infected patients and the distribution of species of these organisms in our hospital were unknown. We therefore aimed to investigate the clinical pattern of dermatophyte infections and to identify the species of these dermatophytes at the Dermatological Clinic of the Hospital for Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok in a 1-year period. Twenty-six patients who had typical dermatophytosis lesions were recruited (27 specimens); 17 were female (65.38%) and 9 (34.62%) were male. The age range of the patients was 16-92 years. In total, nine dermatophyte isolates were identified by macroscopic and microscopic morphological characteristics. We found Microsporum canis (four isolates), Trichophyton mentagrophytes complex (one), Trichophyton rubrum (two), Trichophyton verrucosum (one), and Trichophyton tonsurans (one). The in vitro susceptibility profiles of seven antifungal agents against the nine dermatophytes were as follows (minimum inhibitory concentration ranges in μg/ml): The results were as follows (MIC ranges in μg/ml): ciclopirox, ≤0.06-0.5, griseofulvin ≤0.06-0.5, itraconazole ≤0.002-0.06, posaconazole ≤0.015-0.03, voriconazole ≤0.02-≥1, fluconazole ≤0.08-8, and terbinafine ≤0.01-0.125. This study represents the current state of dermatophyte infections in a metropolitan area of Bangkok, Thailand.

Sonographic Findings in Necrotizing Fasciitis: Two Ends of the Spectrum

Necrotizing fasciitis is a rare but serious disease, and early diagnosis is essential to reducing its substantial morbidity and mortality. The 2 cases presented show that the key clinical and radiographic features of necrotizing fasciitis exist along a continuum of severity at initial presentation; thus, this diagnosis should not be prematurely ruled out in cases that do not show the dramatic features familiar to most clinicians. Although computed tomography and magnetic resonance imaging are considered the most effective imaging modalities, the cases described here illustrate how sonography should be recommended as an initial imaging test to make a rapid diagnosis and initiate therapy.

Body Site Is a More Determinant Factor than Human Population Diversity in the Healthy Skin Microbiome

We studied skin microbiota present in three skin sites (forearm, axilla, scalp) in men from six ethnic groups living in New York City. Methods. Samples were obtained at baseline and after four days following use of neutral soap and stopping regular hygiene products, including shampoos and deodorants. DNA was extracted using the MoBio Power Lyzer kit and 16S rRNA gene sequences determined on the IIlumina MiSeq platform, using QIIME for analysis. Results. Our analysis confirmed skin swabbing as a useful method for sampling different areas of the skin because DNA concentrations and number of sequences obtained across subject libraries were similar. We confirmed that skin location was the main factor determining the composition of bacterial communities. Alpha diversity, expressed as number of species observed, was greater in arm than on scalp or axilla in all studied groups. We observed an unexpected increase in α-diversity on arm, with similar tendency on scalp, in the South Asian group after subjects stopped using their regular shampoos and deodorants. Significant differences at phylum and genus levels were observed between subjects of the different ethnic origins at all skin sites. Conclusions. We conclude that ethnicity and particular soap and shampoo practices are secondary factors compared to the ecological zone of the human body in determining cutaneous microbiota composition.

Lepromatous leprosy with an uncommon presentation: a case report

28 yr old male presented with asymptomatic nodules and few well to ill defined papules on ears, asymmetrical nerve enlargement and evanescent tender nodules on the extremities without any infiltration of the skin and madarosis. Slit skin smear done from normal skin was BI 6+. Skin biopsy showed features of lepromatous leprosy.

Sterile abscess: A surprise diagnosis?

We present the case of an otherwise healthy female hairdresser of Brazilian origin who started to have pain and swelling in her left arm. An antecubital abscess was surgically treated at another institution and there was good initial wound healing. Swelling then recurred and fistulae appeared in the scar. Our diagnostic workup revealed an isolated intramuscular tuberculous abscess, which was successfully treated by an antituberculous drug regimen.

Quantitative investigation on the distribution of Malassezia species on healthy human skin in Korea

This study concerns a culture research based on the data gathered from Korean subjects to examine distribution of Malassezia yeast. Malassezia yeast were cultivated out of samples from scalp, forehead, chest, arm and thigh. Malassezia restricta was recovered more frequently in the teens and young adults, while M. globosa was the predominant species in subjects older than 50 years of age. The population density of Malassezia yeast was significantly higher in the age group (AG) of 21-30 years compared with other AGs (P < 0.05). It was also significantly higher in the chest compared with the forehead, arm and thigh (P < 0.05). The key is to recognise the existence of a difference in the amount and type of Malassezia species in different AGs as well as body areas, which reflects differing skin lipid levels in various AGs and different body areas.

Case reports: tinea corporis in a 13-year-old German girl due to Trichophyton schoenleinii. Fallbericht. Tinea corporis in einem 13jahrigen Madchen verursacht durch Trichophyton schoenleinii

We report the first case of a tinea corporis with partly profound lesions in a 13-year-old girl on her arms, legs and trunk due to Trichophyton schoenleinii but without any lesion on scalp and hair. Moreover, this is the first case of an infection with Trichophyton schoenleinii in Germany since more than 40 years. The diagnosis was confirmed by microscopy of mycological specimens. Other causes of the skin symptoms could be excluded (atopic dermatitis, bacterial or other fungal infection). Clinical and epidemiological aspects of this anthropophile dermatophyte are briefly reviewed.

Validation and assessment of a blood-donor arm disinfectant containing chlorhexidine and alcohol

BACKGROUND

To minimize the bacterial contamination rate in blood collected from donors, a study was designed to evaluate the suitability of a single-use chlorhexidine-alcohol antiseptic for donor arm preparation at all blood collection venues in Australia.

STUDY DESIGN AND METHODS

A prospective study of bacterial load on the skin was performed on 616 blood donors' arms before and after disinfection using a direct swabbing and plating technique. Disinfection was achieved with a swab containing 1 percent chlorhexidine gluconate with 75 percent alcohol, which was applied to the skin in a prescribed method. Feedback from blood donors and staff was obtained using questionnaires.

RESULTS

After disinfection, 99 percent of donor arms had bacterial counts of 5 cfu per plate or less, and 99.5 percent had counts of 10 cfu per plate or less, respectively. The mean colony count for all donors after disinfection was 0.39, and the percentage reduction was 99 compared to predisinfection. Sixteen donors (3%) noted transient skin irritation. The majority of staff (64%) preferred not to use the new disinfectant due to the difficulty opening the packaging and an excessive amount of antiseptic solution per pack.

CONCLUSION

The bacteriologic study showed that the disinfectant satisfied the requirements of the Australian Red Cross Blood Service for use to prepare blood-donor arms before venesection. An improvement to the packaging was required before it could be acceptable to all staff.

ORIGINAL PAPER. Relative values of the interventions of diversion and improved donor-arm disinfection to reduce the bacterial risk from blood transfusion

BACKGROUND AND OBJECTIVES

The aim of this study was to demonstrate the efficiency of diverting the initial 20-ml donation from the collection bag and of an improved donor-arm disinfection procedure in reducing bacterial contamination in blood.

MATERIALS AND METHODS

Donations were collected in bags specially manufactured for the study. These bags incorporated two satellite pouches into each of which 20 ml of blood was collected. Blood initially flowed into sample pouch P1, representing a diversion pouch. Pouch P2 was then filled with 20 ml of blood, which allowed us to sample the collection bag after diversion was complete. Blood then flowed into the standard collection bag. The contents of the pouches were aerobically and anaerobically cultured on the BacT/ALERT automated culture system for 7 days. Two procedures were investigated in the study (each involving 1409 blood donations): one analysed the current disinfection procedure; and the other analysed an improved donor-arm disinfection procedure.

RESULTS

The use of diversion alone resulted in a 47% reduction in contamination, and improved donor-arm disinfection alone resulted in a 57% reduction in contamination. Diversion plus improved donor-arm disinfection produced a predicted 77% reduction in contamination.

CONCLUSIONS

The study validates diversion and an improved donor-arm disinfection procedure. In combination, these two interventions produced a substantial reduction in contamination. These procedures are to be introduced by the English National Blood Service to enhance the safety of the blood supply.

Rare variants of Cutaneous Leishmaniasis: Whitlow, paronychia, and sporotrichoid

Cutaneous Leishmaniasis is endemic in certain areas of Pakistan, with the wet form of the disease being the most prevalent. It has a number of morphological variants, which are dependent on the immune status of the host, the subspecies of the Leishmania, and also, to some extent, on the site of involvement. We describe here a case of Leishmaniasis showing two very rare variants, whitlow and paronychial lesions, occurring concurrently with sporotrichoid spread. The patient responded to intramuscular sodium stibogluconate with resolution of the skin lesions.

A superoxide dismutase C mutant of Haemophilus ducreyi is virulent in human volunteers

Haemophilus ducreyi produces a periplasmic copper-zinc superoxide dismutase (Cu-Zn SOD), which is thought to protect the organism from exogenous reactive oxygen species generated by neutrophils during an inflammatory response. We had previously identified the gene, sodC, responsible for the production and secretion of Cu-Zn SOD and constructed an isogenic H. ducreyi strain with a mutation in the sodC gene (35000HP-sodC-cat). Compared to the parent, the mutant does not survive in the presence of exogenous superoxide (L. R. San Mateo, M. Hobbs, and T. H. Kawula, Mol. Microbiol. 27:391-404, 1998) and is impaired in the swine model of H. ducreyi infection (L. R. San Mateo, K. L. Toffer, P. E. Orndorff, and T. H. Kawula, Infect. Immun. 67:5345-5351, 1999). To test whether Cu-Zn SOD is important for bacterial survival in vivo, six human volunteers were experimentally infected with 35000HP and 35000HP-sodC-cat and observed for papule and pustule formation. Papules developed at similar rates at sites inoculated with the mutant or parent. The pustule formation rates were 75% (95% confidence intervals [CI], 43 to 95%) at 12 parent-inoculated sites and 67% (95% CI, 41 to 88%) at 18 mutant-inoculated sites (P = 0.47). There was no significant difference in levels of H. ducreyi recovery from mutant- and parent-inoculated biopsy sites. These results suggest that expression of Cu-Zn SOD does not play a major role in the survival of this pathogen in the initial stages of experimental infection of humans.

[Surgical treatment of patients with consequences of combined trauma of upper extremity complicated by purulent infection]

Result of treatment of 256 patients with consequences of combined trauma of upper extremity was analyzed. In 83 (32.4%) patients the purulent-necrotic complications occurred, caused by mistakes committed on the treatment process phase, especially during rendering the primary aid. It had promoted occurrence of the joint's contracture and ancilosis, osteomyelitis, ischemic contracture and the skin defects as well. Approach to the treatment conduction was in accordance with general principles of the patients orthopedic rehabilitation with consequences of combined trauma of upper extremity. Sanation of purulent focus was performed in 19 patients and microvascular transplantation of tissues--in 13 before restorational procedure was done.

Evaluation of donor arm disinfection techniques

BACKGROUND AND OBJECTIVE

To validate a standardized optimal national procedure for donor arm disinfection.

MATERIALS AND METHODS

A direct swabbing and plating technique was used to enumerate bacteria present on the arm pre- and postdisinfection. Twelve donor arm disinfection techniques were evaluated.

RESULTS

The Medi-Flex Adapted method, consisting of a two-stage process with an initial application of isopropyl alcohol followed by tincture of iodine, produced the best arm disinfection. A percentage reduction in bacterial counts of 99.79% (logarithmic reduction of 2.67) was obtained. Postdisinfection, 70% of donors had bacterial counts of zero, and 98% had counts of 10 or less.

CONCLUSION

The Medi-Flex disinfection method offers the English National Blood Service a validated, optimal 'best practice' disinfection technique and should contribute significantly to the reduction in risk of transmission of bacteria by transfusion.

[The skin microflora of the upper extremities as the source of suppurative diseases of the hand and fingers]

The parallel bacteriologic studies of microflora of skin of the upper extremities and pus in purulent diseases of the hands and digits in workers of the combine plant was carried out. It was established that besides Staphylococcus aureus, the haemolytic forms of coagulase-negative species, in particular S. hyicus, S. epidermidis, S. haemolyticus, S. warneri, were the agents of purulent-inflammatory processes both in monocultures and in associations. Incidence of isolation of staphylococci and density of bacterial populations depend on the use of oils and emulsions in the manufacturing process.

Phaeohyphomycosis from Exphiala jeanselmei with concomitant Nocardia asteroides infection in a renal transplant recipient: case report and review of the literature

A 59-year-old black man who received a cadaveric renal transplant 15 months earlier developed subcutaneous nodules on his right upper extremity that were identified as phaeohyphomycosis caused by Exophiala jeanselmei. The man was admitted 4 weeks later with a swollen left arm and had Nocardia asteroides in this area and in the apex of his left lung. He was treated with surgical excision, and itraconazole, imipenem-cilastatin, and trimethoprim-sulfamethoxazole. With the potential presence of more than one microorganism in an immunocompromised patient, it is important to identify and differentiate them correctly to direct appropriate therapy.

Fatal Clostridium perfringens sepsis from a pooled platelet transfusion

A male patient with acute myeloid leukaemia received a pooled platelet preparation prepared by Optipress system on the last day of its shelf life. The patient collapsed after two-thirds of the contents had been transfused. Clostridium perfringens was isolated from the platelet bag within 18 h of the acute event. Metronidazole, gentamicin and Clostridium antiserum were then administered in addition to the broad spectrum antibiotics started previously. However, the patient died 4 days after the platelets were transfused. The cause of death was given as cardiovascular shock, entirely compatible with an overwhelming bacteraemic and septic episode. A coroner's verdict of accidental death due to transfusion of a contaminated unit of platelets was recorded. On subsequent investigation Cl. perfringens type A serotype PS68,PS80 (identical to that found in the platelet bag) was cultured from the venepuncture site of the arm of one of the donors who contributed towards the platelet pool. The donor had two young children and frequently changed nappies. Faecal contamination of the venepuncture site was the suspected source for the transmission of Cl. perfringens, an organism commonly found in the soil and intestinal tract of humans. This case dramatically highlights the consequences of transfusing a bacterially contaminated unit. It is vital that such incidents are investigated and reported so that the extent of transfusion-associated bacterial transmission can be monitored and preventative measures taken if possible.

Cellulitis associated with an oral source of infection in breast cancer patients: report of two cases

We present 2 patients with prior lumpectomy, axillary node dissection and radiation therapy for treatment of breast cancer, who subsequently developed arm and chest cellulitis associated with an oral infection (gingivitis with bacteremia in one patient, and dental abscess in another). Our findings suggest that hematogeneous seeding of the compromised extremity and/or breast from the oral cavity should be considered as a possible cause of cellulitis in breast cancer patients.

Infection of the upper extremity by Mycobacterium marinum in a 3-year-old boy--diagnosis by 16S-rDNA analysis

A 3-year-old boy developed several subcutaneous nodular lesions on his right arm. Based on the histological examination of one of these nodules furunculosis was suspected and cefuroxime was tentatively given. However, acid-fast bacilli were then detected in the tissue specimen and a few colonies of acid fast, gram-positive rods grew on blood agar. Definitive species diagnosis (Mycobacterium marinum) was rapidly achieved by automated sequencing of amplified 16S-rDNA and antimicrobial therapy was adjusted according to the available literature. After 3 weeks of treatment with clarithromycin, rifampicin and protionamid regression of the nodular lesions was evident.

Effectiveness of the closed method utilizing iodophors in the degermination of hands and arms of the surgical team and operative sites

A closed method utilizing the E-Z Prep Tray and the E-Z Scrub with iodophors is an effective means of degerming the hands and arms of surgical team members and the patients' operative sites. Fifty unselected surgical cases were evaluated bacteriologically, pre-preparation, post-preparation, and post-operatively. The data indicated that bacterial colony counts decreased, and the postoperative wound infection rate decreased to two percent.

The localization and distribution of gram-positive cocci in normal skin and in lesions of acne vulgaris

The localization of gram-positive cocci in the normal skin and in the lesions of acne vulgaris was investigated using fluorescein-labeled antiserum raised to gram-positive, coagulase-negative cocci. The cocci were found in 10 of 19 specimens from normal facial skin and in 3 of 11 specimens from the normal skin of the rest of the body. The bacteria were found mostly in the openings of follicles, but in 6 of 10 facial skin specimens, they were also present deeply in the lumina of the dilated sebaceous follicles near the sebaceous glands. Cocci were found in 5 of 6 noninflammatory acne comedones. In inflammatory acne they were demonstrated not only in the follicular canals but also sparsely in the infiltrate surrounding the follicles.

The flora of renal haemodialysis shunt sites

During investigations of the microbial flora of the skin over haemodialysis shunt sites it has not proved possible to predict clinical infection by a preceding colonization of the shunt site with a pathogenic organism. The normal non-pathogenic flora of the sites is not specifically related to the flora of other sites on the body though Staphylococcus aureus on a shunt site appeared to be acquired principally from the nose when the shunt was in the arm or from the perineum when the shunt was in the leg. Cimino shunt sites had a greater density of organisms than did Scribner shunt sites; this may be related to the disinfection procedures.