Recurrent Bacterial Skin Infections in a Jiu-Jitsu Athlete

The efficacy of dupilumab in pediatric patients with severe eczema presenting in the setting of elevated immunoglobulin E (IgE) levels and recurrent bacterial skin infections is not well-understood. Here we present the case of a child with elevated IgE levels in whom dupilumab treatment led to remarkable control of his eczema and recurrent skin infections. We also review the use of dupilumab in other patients with molecularly proven cases of hyper IgE (HIGE) syndrome. Our case supports the notion that dupilumab may have a seminal application in treating severe eczema that occurs in the setting of elevated IgE levels and recurrent bacterial skin infections.

IntroductionSkin and soft tissue infections (SSTI) caused by Panton-Valentine leukocidin (PVL)-producing strains of Staphylococcus aureus (PVL-SA) are associated with recurrent skin abscesses. Secondary prevention, in conjunction with primary treatment of the infection, focuses on topical decolonization. Topical decolonization is a standard procedure in cases of recurrent PVL-SA skin infections and is recommended in international guidelines. However, this outpatient treatment is often not fully reimbursed by health insurance providers, which may interfere with successful PVL-SA decolonization.AimOur goal was to estimate the cost effectiveness of outpatient decolonization of patients with recurrent PVL-SA skin infections. We calculated the average cost of treatment for PVL-SA per outpatient decolonization procedure as well as per in-hospital stay.MethodsThe study was conducted between 2014 and 2018 at a German tertiary care university hospital. The cohort analyzed was obtained from the hospital’s microbiology laboratory database. Data on medical costs, DRG-based diagnoses, and ICD-10 patient data was obtained from the hospital’s financial controlling department. We calculated the average cost of treatment for patients admitted for treatment of PVL-SA induced skin infections. The cost of outpatient treatment is based on the German regulations of drug prices for prescription drugs.ResultsWe analyzed a total of n = 466 swabs from n = 411 patients with recurrent skin infections suspected of carrying PVL-SA. PVL-SA was detected in 61.3% of all patients included in the study. Of those isolates, 80.6% were methicillin-susceptible, 19.4% methicillin-resistant. 89.8% of all patients were treated as outpatients. In 73.0% of inpatients colonized with PVL-SA the main diagnosis was SSTI. The median length of stay was 5.5 days for inpatients colonized with PVL-SA whose main diagnosis SSTI; the average cost was €2,283. The estimated costs per decolonization procedure in outpatients ranged from €50-€110, depending on the products used.ConclusionOur data shows that outpatient decolonization offers a highly cost-effective secondary prevention strategy, which may prevent costly inpatient treatments. Therefore, health insurance companies should consider providing coverage of outpatient treatment of recurrent PVL-SA skin and soft tissue infections.

Antimicrobial peptides are an integral part of the epithelial innate defense system. Dermcidin (DCD) is a recently discovered antimicrobial peptide with a broad spectrum of activity. It is constitutively expressed in human eccrine sweat glands and secreted into sweat. Patients with atopic dermatitis (AD) have recurrent bacterial or viral skin infections and pronounced colonization with Staphylococcus aureus. We hypothesized that patients with AD have a reduced amount of DCD peptides in sweat contributing to the compromised constitutive innate skin defense. Therefore, we performed semiquantitative and quantitative analyses of DCD peptides in sweat of AD patients and healthy subjects using surface-enhanced laser desorption ionization time-of-flight mass spectrometry and ELISA. The data indicate that the amount of several DCD-derived peptides in sweat of patients with AD is significantly reduced. Furthermore, compared with atopic patients without previous infectious complications, AD patients with a history of bacterial and viral skin infections were found to have significantly less DCD-1 and DCD-1L in their sweat. To analyze whether the reduced amount of DCD in sweat of AD patients correlates with a decreased innate defense, we determined the antimicrobial activity of sweat in vivo. We showed that in healthy subjects, sweating leads to a reduction of viable bacteria on the skin surface, but this does not occur in patients with AD. These data indicate that reduced expression of DCD in sweat of patients with AD may contribute to the high susceptibility of these patients to skin infections and altered skin colonization.

Primary immunodeficiency (PID) was previously considered an extremely rare pathology in childhood, now it has been established that congenital deficit of quantity and functional activity of the lymphocytes, platelets and neutrophils occurs in 1:500–1:4000 newborns. Severe chronic neutropenia in PID is characterized by a stable decrease or absence of circulating neutrophils (<500/cm) and accompanied with recurrent bacterial skin and lung infections. We identified 135 patients with PID. Patient’s examination included clinical observation, general blood test, immunological tests, X-ray of chest and ultrasound examination. We report that six children with PID had significant hematological disorders. The age of these patients was from 1 month to 13 years. Four of them were born from consanguineous marriages, 3 patients died before the age of 5 years. 2 patients with PID had congenital neutropenia, repeated skin infections, pneumonia, diarrhea, stomatitis. Two brothers with WAS syndrome had repeated bleeding, skin hemorrhages, anemia, lymphadenitis, hepatosplenomegaly. The platelet count was about 30–70/ml. Genetic analysis in these patients revealed a hemizygous c.12_13insGG mutation in exon 1 of the WAS gene. 2 children with SCID were found to be carriers of thalassemia B. All our patients showed a significant decrease in Ig classes, CD3+, CD4+, CD8+ and NBT test. We conclude that patients with suspected PID should be continuously monitored by Immunologists and Hematologists. Timely detection of hematological disorders in patients with PID allows for correct diagnosis and prevents fatal complications. Genetic testing can help in making a definitive diagnosis. Supported by Azerbaijan Medical University

Objective To study the clinical features, diagnosis, treatment and genetic characteristics of granulomatosis disease (CGD) in neonates, and to improve the understanding of CGD. Method Clinical manifestations and treatments of one patient with CGD and in our hospital were analyzed. Key words including infant, newborn, chronic granulomatous lung and aspergillus infection were searched in Chinese medical databases, PubMed and Embase until 2018 September. The clinical features and genetic mutations of CGD reported in literature were summarized. Result The patient in our hospital was a full-term male infant naturally delivered with birth weight of 3 400 g. The onset of the disease was on the 19th day after birth, and the initial clinical manifestations included fever, cough, and then pulmonary abscess, diarrhea, recurrent skin infection, and infection. Anti-infection and symptom-alleviating treatments were not effective, and weight gain was poor. Laboratory examination indicated bacterial and fungal infection. The neutrophil respiratory burst test was positive and indicated CGD. Hetero-zygotic frameshift mutation [c.1599-1602delAGTT (p.V534Sfs*12)] of CYBB gene 13 exon was detected and the diagnosis of CGD was confirmed. The mother carried the heterozygous mutation and the father didn′t. Antifungal therapy was continued after the children got better and discharged from hospital. The patient was followed up until 3-month-old and his condition was stable. Our literature review revealed 28 reports including 108 cases of CGD infants, including 79 male cases (73.1%) and 21 female cases (19.4%). Most of the CGD infants (79/108, 73.1%) had the onset within 2 weeks of life. The main clinical features included pneumonia/pulmonary abscess/pleural effusion (87.0%), diarrhea (58.3%), perianal abscess (35.2%), skin (53.7%), (41.7%), and tuberculosis (26.9%). 75 cases had positive neutrophil respiratory burst test (69.4%), and 95 cases were diagnosed using genetic tests (88.0%). Over 300 loci of the CYBB gene mutation had been reported contributing to the disease. 28 cases had abnormal family history (25.9%), 19 cases received hematopoietic stem cell transplantation (17.6%), 41 cases had clinical improvement (38.0%), and 35 cases died (32.4%). Conclusion CGD is rare in neonatal period. The main clinical manifestations included recurrent with pathogens like aspergillus, tuberculosis and others. CGD can be diagnosed based on recurrent multiple bacterial or fungal infections, neutrophil respiratory burst test and gene tests. CGD should be considered among children with recurrent infections at early life stage, especial1y those with poor maternal history or positive family history. Key words: Granulomatous disease, chronic; Lung abscess; Aspergillus; Infant, newborn

Our knowledge of the current epidemiology of skin infections among wrestlers is limited. To analyze and report the epidemiology of skin infections among National Collegiate Athletic Association (NCAA) men's wrestling student-athletes during the 2009-2010 through 2013-2014 academic years. Descriptive epidemiology study. Aggregate skin infection and exposure data collected by the NCAA Injury Surveillance Program. Collegiate men's wrestling student-athletes. All viral, bacterial, or fungal skin infections reported by athletic trainers at 17 NCAA programs were analyzed, providing 35 team-seasons of data. Skin infection rates per 10 000 athlete-exposures (AEs), rate ratios, skin infection proportions, and skin infection proportion ratios were calculated. The athletic trainers reported 112 skin infections contracted by 87 student-athletes across 78 720 AEs. The overall skin infection rate was 14.23/10 000 AEs (95% confidence interval [CI] = 11.59, 16.86). Of the skin infections identified, 22.3% (n = 25) were recurrent skin infections. Most skin infections (65.2%) were attributable to 5 team-seasons (range, 11-19 infections). Most skin infections occurred during the regular season (n = 76, 67.9%), were identified during practice (n = 100, 89.3%), and resulted in ≥24 hours' time loss (n = 83, 74.1%). The rate for viral skin infections was 1.72 times the rate for bacterial skin infections (95% CI = 1.09, 2.72) and 2.08 times the rate for fungal skin infections (95% CI = 1.28, 3.39). Fungal skin infections more often resulted in time loss <24 hours compared with all other skin infections (75.0% versus 12.5%; infection proportion ratio = 6.00; 95% CI = 3.30, 10.92). Our findings highlight the contagiousness of skin infections and suggest that skin infection rates may be attributable to high incidences among particular teams.

We conducted a double-blind, controlled trial of low-dose (150 mg/d) oral clindamycin hydrochloride vs placebo to prevent recurrent staphylococcal skin infections. Twenty-two patients (11 in both the placebo and clindamycin treatment groups) completed the trial and were assessable. The two groups did not differ as to age, sex, race, or the number of recurrent abscesses preceding the trial. In pretrial evaluations, no patient had hypogammaglobulinemia or abnormal neutrophil function. Sixty-four percent (7/11) of the placebo-treated patients had a recurrent abscess within three months of enrollment whereas 82% (9/11) of the patients treated with clindamycin were free of any infection during the three-month treatment period. Of the nine patients who responded to clindamycin treatment, six did not have a recurrent infection for at least nine months after discontinuing antibiotic therapy. All patients tolerated the regimen without side effects. We conclude that a three-month course of low-dose oral clindamycin is an effective, convenient, well-tolerated, and often durable approach to prevention of recurrent staphylococcal skin infections.

Pancreatic agenesis is a rare cause of neonatal diabetes mellitus (NDM). It can be associated with malformations of the heart, the biliary tract, and the cerebellum. We report an infant with NDM because of pancreatic agenesis, intra-uterine growth retardation, dysmorphic features, and recurrent bacterial infections. He was born to healthy consanguineous parents. With adequate replacement of insulin and pancreatic enzymes, his blood glucose levels were controlled and his weight slowly increased. However, he continued to develop recurrent serious bacterial infections and died at the age of 11 months with sepsis and respiratory failure. Analysis of the PTF1A and PDX1 genes, which have been associated with congenital agenesis of the pancreas, did not reveal any mutation. Genetic abnormalities of chromosome 6 associated with transient neonatal diabetes as well as mutations in the KCNJ11 and ABCC8 genes encoding the pancreatic potassium channel were also excluded as a cause of the NDM in this patient. The association of permanent neonatal diabetes because of pancreatic agenesis, dysmorphism, and non-specific immunodeficiency is previously undescribed and may represent a new possibly autosomal recessive syndrome.

ObjectivesCellulitis is a common and often recurrent bacterial skin infection. Antibiotics are the first-line treatment for cellulitis and antibiotic prophylaxis is a known preventive measure for frequent recurrence. Evidence for other interventions targeting known risk factors (secondary prevention) remains unclear. This review evaluates the evidence for managing risk factors to prevent recurrent limb cellulitis.Study designA systematic review of studies on cellulitis risk factor management, excluding antibiotic prophylaxis, was conducted. Five databases were searched in February 2023 and June 2024. Eligible studies underwent narrative synthesis and quality assessment. Databases searched included MEDLINE, Scopus, Web of Science, CINAHL, and EMBASE, for the time period 1996-June 2024.Data synthesisSummary of major results; Of 1,116 screened papers, 25 met the criteria. Study designs varied, with only one randomized controlled trial. Nearly all studies addressed lymphoedema, showing that its management, particularly with compression, consistently reduced cellulitis recurrence. Although cellulitis guidelines detail the need to address many risk factors to reduce cellulitis, including tinea and ulcers, we did not find studies that linked the management of these conditions with cellulitis recurrence.ConclusionsEvidence strongly supports lymphoedema management in preventing cellulitis recurrence, studies on other risk factors including skin integrity, are lacking. Studies to support strategies beyond antibiotic prophylaxis are needed.

A 3-year-old Thai boy with diffuse chronic granulomatous mucocutaneous candidiasis, recurrent bacterial skin infection and adrenal insufficiency is reported. Candida albicans was demonstrated in the dermal granuloma. He had a defect in cell-mediated immunity and was anemic. Although therapy with topical clotrimazole, oral iron, systemic antibiotic and low-dose of prednisone gave a dramatic result, he died of disseminated cryptococcosis.

There are numerous racial and ethnic differences in atopic dermatitis (AD) morphology, distributions, texture, and pigmentation that make diagnosing AD challenging across Fitzpatrick skin types. This incredibly complex pathophysiology involves interactions between the innate and adaptive immune system, keratinocytes and sensory nerve cells. When patients attend busy clinic setting, dermatologists frequently have insufficient time to educate patients adequately regarding the multiple factors that are important in managing AD. Management involves parental and patient education as well as pharmacological management such as topical creams, calcineurin inhibitors (cyclosporine), methotrexate, azathioprine, mycophenolate mofetil and newer targeted therapies like dupilumab and JAK inhibitors. Recurrent bacterial skin infections and lichenification are typically associated with moderate to severe AD. Staphylococcus aureus is a gram positive, beta-hemolytic, catalase positive, coagulase positive cocci occurring in clusters. This organism has a predilection for skin (stratum corneum), heart, and the joints. Dupilumab is a new biologic therapy approved by the food and drugs administration (FDA) for the treatment of moderate- severe AD. It blocks the IL-4 and IL-13 signaling, which are key cytokines driving inflammation in AD.

Elevated immunoglobulin E (IgE) levels are commonly associated with allergies. However, high IgE levels are also found in several other infectious and non-infectious disorders. Elevated IgE levels typically suggest allergies, eczema, or recurrent skin infections. Hyperimmunoglobulin E (hyper-IgE) levels typically reflect a monogenic atopic condition or inborn immune defects with an atopic phenotype. The aim of our research is to investigate and observe the clinical characteristics of children with increased IgE levels who have previously manifested infectious diseases. Furthermore, the retrospective study considers other factors, such as demographic characteristics (sex, area/environment, and age), and their effect on IgE serum levels. To answer this question, we conducted a one-year hospital-based retrospective study that included 200 hospitalized children who had at least two viral or bacterial infections in the six months preceding hospitalization. Measurements of IgE and allergen panels (respiratory and digestive) using blood samples revealed that individuals who tested positive for the body's synthesis of hyper-IgE were not observably allergic to any potential allergens despite having higher total serum IgE. According to the results, there was a strong correlation between elevated IgE serum levels and a history of infectious diseases among the patients.

BackgroundChronic edema as a complication of systemic diseases or infections can mimic filarial lymphedema (also known as elephantiasis) and considered so. We describe a case of chronic lymphedema that mimicked elephantiasis in a diabetic man.Case presentationThe patient was a 70-year-old black man, bed-bound at the time of admission following a diagnosis of stroke and hypertension in the previous 5 years. He had been diabetic for 20 years with poorly controlled diabetes mellitus. He suffered recurrent bilateral lower limb skin infections for 5 years prior to admission that culminated into progressive lowerlimb edema. The infections eventually complicated into skin edema, hardening, fissuring, and hyperkeratotic plaques. The physical examination revealed Tinea pedis and bilateral non-pitting edema of lowerlimbs to the level of the knees. Investigations confirmed non-filarial lymphedema-related skin changes. The absence of the classic pebbly/cobblestone skin changes ruled out elephantiasis nostra verrucosa (ENV), with a possibility of it being in the early stages of evolution. The patient’s skin fissuring and infections were successfully treated with antibiotics and antifungals while compression stockings helped to relieve the edema.ConclusionsChronic lymphedema can complicate repeated non-filarial infections of lower limbs. Its fissures are a risk factor for cellulitis, prompting early identification and management of both infections and lymphedema to halt their vicious cycle, especially in at risk populations like diabetics.

We conducted a double-blind, controlled trial of low-dose (150 mg/d) oral clindamycin hydrochloride vs placebo to prevent recurrent staphylococcal skin infections. Twenty-two patients (11 in both the placebo and clindamycin treatment groups) completed the trial and were assessable. The two groups did not differ as to age, sex, race, or the number of recurrent abscesses preceding the trial. In pretrial evaluations, no patient had hypogammaglobulinemia or abnormal neutrophil function. Sixty-four percent (7/11) of the placebo-treated patients had a recurrent abscess within three months of enrollment whereas 82% (9/11) of the patients treated with clindamycin were free of any infection during the three-month treatment period. Of the nine patients who responded to clindamycin treatment, six did not have a recurrent infection for at least nine months after discontinuing antibiotic therapy. All patients tolerated the regimen without side effects. We conclude that a three-month course of low-dose oral clindamycin is an effective, convenient, well-tolerated, and often durable approach to prevention of recurrent staphylococcal skin infections. ( JAMA 1988;260:2682-2685)

Safety of rituximab in rheumatoid arthritis patients with a history of severe or recurrent bacterial infection: Observational study of 30 cases in everyday practice