Acute generalized exanthematous pustulosis: Analysis of cases managed in a Tunisian tertiary hospital

Acute generalized exanthematous pustulosis (AGEP) is a severe and life-threatening cutaneous adverse reaction. Drug-induced AGEP is mainly related to antibiotics. More recently, AGEP following spider bites has been increasingly described. Treatment includes withdrawal of the offending drug and supportive care. In Tunisia, data concerning severe cutaneous adverse reactions (SCARs) in general and especially AGEP is lacking. Herein, we conducted a retrospective study to investigate the epidemiological, clinical characteristics and etiologies of AGEP referred to the Dermatology department. Our study included 32 cases of AGEP. AGEP cases occurred in overall 8.9% of all SCARs referred to the department during the same period study. The majority were females (24 women and 7 men). The median age of the patients was 33 years. A history of psoriasis was reported in 16.1% of patients. All patients presented with an extensive erythematous rash with pinhead pustules. Neutrophil hyperleukocytosis (greater than 7000/mm3) was noted in 17 patients (63% of cases). It was associated with hypereosinophilia exceeding 500 elements/mm3 in 8 cases (29.6%). Drug-induced AGEP was reported in 53% of cases. Antibiotics were implicated in the majority of cases. Delay in onset ranged from 15hours to 7 days, with an average of 2.8 days. A non-drug-induced etiology was considered if the pharmacological investigation was negative, or if a clear non-drug trigger was found. It was retained in ten cases (48.4% of all observations). Spider bites were revealed in 8 cases. AGEP represents a severe, usually drug-related skin reaction. It is classified as a type IVd reaction mediating T cell-related sterile neutrophilic inflammatory response. It typically occurs within 24-48 h of ingestion of the offending drug. Antibiotics are the most common drug family to cause AGEP. Spider bites were involved in 25.8% of cases in our study, as important as antibiotic-induced AGEP. Analysis of the particularities of AGEP according to etiology, whether drug-induced or not, revealed the presence of an initial escarotic lesion (P=0.01) and the finding of blood hypereosinophilia (P=0.014) in the non-drug AGEP group were the distinguishing features. Blood hyperesoniophilia, more frequent in the non-drug AGEP group, suggests a pathophysiology probably different from that of the drug AGEP group. Clinicians should be aware of both etiologies. Our study focuses on the importance of AGEP associated with spider bite as a potential triggering factor in Tunisia.

Septic shock caused by Capnocytophaga canimorsus in a patient with heterozygous Pelger-Huët anomaly

Capnocytophaga canimorsus is a Gram-negative bacillus of the commensal flora of dogs and cats that can cause infections in humans through bites, scratches or contact with oral secretions. It can be difficult to identify in clinical microbiology laboratories because of the need for specific culture media. We present the case of a patient with no relevant medical history who was admitted with septic shock, where blood smear examination was crucial for the etiologic diagnosis of Capnocytophaga canimorsus infection. The patient was also diagnosed Pelger-Huët anomaly, a condition causing a defect in neutrophil chemotaxis, which may have contributed to the severity of the infection.

Dermoscopy of skin parasitoses, bites and stings: a systematic review of the literature

Besides classic applications, dermoscopy has gained significant appreciation also for non-tumoral dermatoses (general dermatology). In this field, skin parasitoses (infestations), bites and stings have been reported among the conditions that may benefit most from dermoscopic examination. However, published data on this topic are sparse and often lack a standardized analytical approach. In this systematic review of the literature, we sought to summarize available data on dermoscopy of cutaneous parasitoses, bites and stings, analysing dermoscopic features and used setting (polarisation or not/magnification), pathological correlation and level of evidence of published studies as well as trying to align dermoscopic terminology of reported findings following a standardized methodology. A total of 150 publications addressing 29 different dermatoses and reporting 96 different dermoscopic findings were included in the analysis. Most of the them displayed a level of evidence of V (113 single case reports and 36 case series), with only one study featuring a level of evidence of IV (case-control study). Additionally, our analysis also displayed poor uniformity in the terminology used in published articles (even for the same dermatosis). Therefore, albeit promising, dermoscopy of cutaneous parasitoses, bites and stings needs future systematized studies for a better characterization.

[Dog bites, a current problem in our environment]

AIMS

Dog bites are frequent reason for consultation in pediatrics emergency department. Despite in our environment dog bites are rarely lethal, some of these accidents can have serious aesthetics consequences. The main goal of this article is to analyze dog bites casuistry and their impact in our community.

MATERIAL AND METHODS

Retrospective review of patients treated for dog bite in a tertiary pediatric center between 2013-2018. We studied patient's demographic variables, bite localization, dog-patient relationship, antibiotic therapy, need for admission, complications and secondary sequelae.

RESULTS

256 cases were analyzed (average age 6.4 years), 133 boys (51.9%) and 123 girls (48%). In 153 cases, the aggressor dog was from the patient's familiar environment (59.8%). The most frequent location of the wounds was head and neck (94.1%), followed by extremities (4.7%) and genitals (1.6%). In 227 cases (88.7%) antibiotics were administered. Wound infection was the most frequent complication, occurring in 5 patients (2%). 20 patients (7.8%) required hospital admission with a mean stay of 1.6 days. Aesthetic sequelae were described in 10 cases (3.9%), 7 of which required correcting surgery.

CONCLUSIONS

Dog bites persist as a frequent reason for medical consultation, most of them are provoked by patient familiar dogs. Wound infection represents the major complication, and the facial aesthetic sequelae are the most frequent indication for surgical intervention. We consider due to the amount of dog bites and their sequelae, the inclusion of preventive measures against these accidents in home prevention guidelines could be useful to reduce the incidence of these injuries.

Transmission of HIV infection by severe bites

A 56-year-old man acquired HIV infection as the result of bites that caused severe tissue injuries. The features of the biting episode that led to transmission of infection were very similar to those in four other patients reported to have acquired HIV infection as the result of bites. Post-exposure prophylaxis should be recommended for people who have suffered bites that caused significant tissue injuries, inflicted by a person with known HIV infection, who had visible blood staining of their saliva at the time of biting, and an HIV viral load known or presumed to be greater than 3.0 log10 copies/ml.

Scoping decades of dog evidence: a scoping review of dog bite-related sequelae

OBJECTIVES

There has been considerable literature published focusing on various sequelae to dog bites over the last three decades. Much of the literature has focused on rabies, particularly canine rabies variant, which accounts for the majority of rabies deaths worldwide. This paper describes the complications, the pathogens, and other sequelae resulting from dog bites documented in the literature.

METHODS

This paper used evidence found through a scoping review which charted the published peer-reviewed and non-peer-reviewed gray literature and online information relating to dog bite incidents. Each complication or sequela was additionally assessed from the viewpoint of Canadian Indigenous, rural, and geographically remote communities, which experience a high number of dog bite incidents annually.

SYNTHESIS

Peer-reviewed literature (N = 693; case report, original research, and review articles) provided detailed information on specific pathogens, infections, and diseases of interest, especially rabies. However, in addition to these, the sequelae from dog bites may include moderate to severe injuries that further result in anxiety around dogs or post-traumatic stress disorder (PTSD).

CONCLUSIONS

While a lot of focus in the literature is on rabies as a sequela to dog bites, the impacts of anxiety and PTSD are not as well articulated. Treatment of dog bite injuries may be standardized; however, improved collaborations between diverse health professionals (physicians, veterinarians, counseling services, animal behaviourists, and others) could be of considerable benefit in decreasing the effects of dog bites.

Hand Infections

Hand infections can lead to debilitating and permanent disability, particularly if they are not treated promptly or properly. The unique anatomy of the hand, with its numerous enclosed and confined spaces, warrants special considerations. For instance, infections in deep spaces of the hand may require surgical drainage despite an appropriate course of antimicrobial treatment. Thorough history and examination are crucial in guiding further investigations and management, particularly because there are numerous mimickers of hand infections, such as gout and pseudogout.

A shark attack treated in a tertiary care centre: Case report and review of the literature

Although uncommon, shark attacks can lead to devastating outcomes for victims. Surgeons also face unique challenges during operative management such as exsanguination, shock, specific injury patterns and infections. This case report presents the management of a 39-year-old previously healthy female attacked by a shark while on vacation in Mexico. The patient sustained severe injuries to her left arm and her left thigh. She was transferred to a Canadian institution after ambiguous operative management in Mexico and presented with no clear antibiotic coverage and a Volkman’s contracture of the left upper extremity. In total, the patient underwent four washouts of wounds, two split-thickness skin grafts, one free anterolateral thigh flap, and one free transverse rectus abdominus myocutaneous flap for the reconstruction and salvage of the left lower extremity. This article highlights the specifics of this case and describes important points in managing these devastating injuries.

Acute Osteomyelitis in the Hand Due to Dog Bite Injury: A Report of 3 Cases

As many people keep small dogs as pets, dog bites are common injuries, accounting for approximately 80%-90% of all animal bite injuries. These injuries usually occur on the upper extremities, most commonly on the fingers. Most of these injuries appear as simple lacerations or abrasions of the skin. Common symptoms include inflammatory reactions of the soft tissue, such as pain, swelling, erythema, and cellulitis. However, the complications of small dog bites may include joint or cartilage injuries, including acute osteomyelitis. Once osteomyelitis develops, it is difficult to diagnose since it has a latency period of approximately 2 weeks. Plain radiography, magnetic resonance imaging, and 3-phase bone scans should be performed when acute osteomyelitis is suspected, and broad-spectrum empiric antibiotic treatment should be administered for approximately 8-12 weeks. We report 3 very rare cases of acute osteomyelitis that occurred after a dog bite injury.

Contaminated wounds: Effectiveness of debridement for reducing bacterial load

Surgical management of contaminated hand wounds may seem anecdotal, but such injuries actually account for an appreciable amount of the activity in emergency hand centers, and recommendations put forward by scientific societies differ. Dealing effectively with this public health issue calls for clarifying the usefulness of the various available treatments. Our study's objective was to determine the effectiveness of surgical debridement. In this prospective study, 92 patients with contaminated hand wounds underwent surgical debridement. Selection criteria included the length of time between injury and treatment, and the mechanism of injury. Patients with infected wounds, those treated by antibiotics, who were immunosuppressed or had osteoarthritis were excluded. Skin samples were collected both before and after debridement. In 62% of cases, the wounds were contaminated before debridement. Following the procedure, 87% of the bacterial smears were negative. The comparison between debridement and smear results was statistically significant (Student's t test, P<0.001). Surgical debridement, with appropriate irrigation, can effectively eradicate bacterial flora due to contamination.

Bite wounds and antibiotic prescription among patients presenting to an Australian emergency department

INTRODUCTION

Emergency department presentations after mammalian bites may be associated with injection of bacteria into broken skin and may require prophylactic antibiotics to prevent subsequent infection. We aim to describe the epidemiology of patients presenting with a mammalian bite injury and antibiotic choice to an Australian adult tertiary centre.

METHODS

A retrospective cohort study was performed capturing all presentations after mammalian bite wounds between 01 Jan 2014 and 31 Dec 2014. An explicit chart review was conducted to determine management of each case. Cases were subgrouped into high- and low-risk groups as defined by the Australian Therapeutic Guidelines for animal bites.

RESULTS

There were 160 cases of mammalian bite wounds included, with 143 (89.4%) patients grouped as high-risk and 17 (10.6%) patients identified as low-risk. High-risk features were delayed presentation > 8 hours (57 patients, 35.6%), bites to the head, hand or face (113 patients, 70.6%), and puncture wounds unable to be adequately debrided (74 patients, 46.3%). There was a significant association with delayed presentation of more than eight hours and clinically established infection [OR 36.2; 95% CI: 12.6-103.6; P < 0.001]. Prescriptions for antibiotics that adhered to current guidelines occurred in 99 (61.9%) cases.

CONCLUSIONS

This study highlights variability in antibiotic prescription practice among clinicians and the need for ongoing education on antibiotic stewardship. Intervention strategies, including ongoing education, are indicated to improve adherence to antibiotic guidelines.

Clinical manifestations and experimental studies on the spine extract of the toadfish Porichthys porosissimus

Toadfish are fish from the family Batrachoididae that are found in marine and brackish environment around the world. Among the toadfish, Porichthys genus is very common, where Porichthys porosissimus, also called Atlantic Midshipman is found in Southwest Atlantic, from Rio de Janeiro, Brazil to eastern Argentina. There was no consensus about the classification of the genus Porichthys as venomous fish because so far there are no published studies regarding human envenomations and/or toxic activities induced in animal models. Herein, we report two conclusive envenoming in human beings caused by P porosissimus spines, with clear signs and symptoms that were very important for the development of our experimental studies. We demonstrated that the P. porosissimus spine extract, now venom, can induce nociceptive and edematogenic responses in mice as well an induction of an inflammatory response elicited by intravital microscopy and leukocyte migration. Finally, we identified in the P. porosissimus spine extract, through analysis by mass spectrometry, the presence of proteins previously detected in the venoms of other fish species and other venomous animals. We believe that based on our studies we will dismiss the non-venomous nature of this fish and clarify this issue.

Examining the utility of a bite-count-based measure of eating activity in free-living human beings

The obesity epidemic has triggered a need for novel methods for measuring eating activity in free-living settings. Here, we introduce a bite-count method that has the potential to be used in long-term investigations of eating activity. The purpose of our observational study was to describe the relationship between bite count and energy intake and determine whether there are sex and body mass index group differences in kilocalories per bite in free-living human beings. From October 2011 to February 2012, 77 participants used a wrist-worn device for 2 weeks to measure bite count during 2,975 eating activities. An automated self-administered 24-hour recall was completed daily to provide kilocalorie estimates for each eating activity. Pearson's correlation indicated a moderate, positive correlation between bite count and kilocalories (r=0.44; P<0.001) across all 2,975 eating activities. The average per-individual correlation was 0.53. A 2 (sex)×3 (body mass index group: normal, overweight, obese) analysis of variance indicated that men consumed 6 kcal more per bite than women on average. However, there were no body mass index group differences in kilocalories per bite. This was the longest study of a body-worn sensor for monitoring eating activity of free-living human beings to date, which highlights the strong potential for this method to be used in future, long-term investigations.

Lesions caused by animals in the Autonomous Province of South Tyrol in 2010: fact-finding for prevention

Lesions caused by animals, in particular by dogs, are a health issue to which public opinion often reacts sensitively. To effectively manage and prevent these events, it is therefore essential to evaluate the public health impact of this phenomenon and to identify the main connected risk factors. The aim of the present survey in the Autonomous Province of Bolzano was to collect various epidemiological variables helpful in understanding the problem at local level. The incidence and impact on Health Services of human lesions by several animal species for the year 2010 is presented, as well as a more detailed analysis of dog bites, giving a profile of the victims and of the animals involved. Different factors (geographical, contextual, seasonal and relational) that can be associated with episodes where dogs react aggressively to humans are illustrated. On the basis of the collected data, recommendations are given to prevent risk situations.

Catfish stings: A report of two cases

Venomous catfish stings are a common environment hazard worldwide. Although these stings are often innocuous, significant morbidity may result from stings, including severe pain, retained foreign bodies, infection, respiratory compromise, arterial hypotension, and cardiac dysrhythmias. Treatment included hot water immersion, analgesia, wound exploration, and prophylactic antibiotics. In this article, two cases of stings by catfish referred to the poison center of Noor Hospital, Isfahan University of Medical Sciences and their treatments have been reported.

Necrotizing fasciitis resulting from human bites: A report of two cases of disease caused by group A streptococcus

Necrotizing fasciitis is a serious and potentially life-threatening condition. Although bite wounds are common, they are not frequently reported as a cause of necrotizing fasciitis. In the present article, two cases of bite-associated necrotizing fasciitis caused by group A streptococcus are reported. Previously published cases are also reviewed.

Environmental risks to Canadian children travelling overseas

Canadian children and youth travelling overseas face numerous environmental risks, including trauma, extreme temperatures, sun exposure, high altitudes, environmental pollution, and a variety of bites, stings and envenomations. Because skilled emergency response is limited or nonexistent in places where serious illness or injury is most likely to occur, avoiding or limiting these risks is imperative. Travel and paediatric health care providers must be able to identify environmental risks and to advise parents appropriately. Anticipating potential dangers and planning preventive strategies in advance can reduce both parental anxiety and the risk to children.