Pyoderma Gangrenosum After Insertion of a Hemodialysis Catheter: Koebner Phenomenon, Systemic Inflammatory Response Syndrome, and a Delay in Diagnosis.

Rationale: Pyoderma gangrenosum is a rare neutrophilic dermatosis. Misdiagnosis of pyoderma gangrenosum as an infection is not uncommon. Pyoderma gangrenosum can be associated with Koebner phenomenon and rarely results in systemic inflammatory response syndrome and shock. Presenting concerns of the patient: A 61-year-old woman had recently started maintenance hemodialysis, using a tunneled catheter. She was admitted with fever and signs of inflammation at the catheter exit site and along the tunnel. Diagnoses: The initial diagnosis was catheter-related tunnel infection. The exit site broke down into a 5 cm × 5 cm lesion typical of pyoderma, and a new similar lesion developed at a subcutaneous injection site in her abdomen. Clinical diagnosis of pyoderma gangrenosum was made. She remained febrile despite broad antibiotic coverage and catheter removal and developed systemic inflammatory response syndrome (SIRS) that necessitated transfer to intensive care unit. Interventions: She responded well to fluids and intravenous steroids. Viral and bacterial cultures were negative throughout; echocardiography and computed tomography were unrevealing. Insertion of a new hemodialysis catheter was deferred as long as clinically possible, was undertaken while the patient was taking steroids, and was uncomplicated. Outcomes: She remained hemodynamically stable and was discharged after rehabilitation. Her wounds slowly granulated and healed. Steroids were tapered. Teaching points: To our knowledge, this is the first case report of a patient with pyoderma gangrenosum developing at the site of tunneled hemodialysis catheter. Our patient developed SIRS with no evidence of infection. We summarize 11 previous case reports of pyoderma leading to SIRS and responsive to steroids.

Justification: Le pyoderma gangrenosum est une dermatose neutrophile rare que l'on méprend souvent d'abord pour une infection. Cette affection qui peut être associée au phénomène de Koebner entraîne rarement un syndrome de réponse inflammatoire systémique (SRIS) et un choc. Présentation du cas: Une femme de 61 ans qui avait récemment amorcé un traitement d'hémodialyse d'entretien par cathéter tunnelisé. À l'admission, la patiente présentait de la fièvre et des signes d'inflammation au point d'émergence du cathéter et le long du tunnel. Diagnostic: On a d'abord diagnostiqué une infection du tunnel liée au cathéter. Le point d'émergence s'est étendu en une lésion de 5 cm x 5 cm typique du pyoderma et une nouvelle lésion similaire s'est développée sur l'abdomen à un point d'injection sous-cutanée. Un diagnostic clinique de pyoderma gangrenosum a été établi. La fièvre a persisté malgré une antibiothérapie étendue et le retrait du cathéter; la patiente a développé un SRIS qui a nécessité son transfert à l'unité des soins intensifs. Intervention: La patiente a bien répondu à l'administration de liquides et de stéroïdes par voie intraveineuse. Les cultures virales et bactériennes sont demeurées négatives tout au long; l'échocardiographie et la tomodensitométrie étaient non révélatrices. L'insertion d'un nouveau cathéter d'hémodialyse a été reportée aussi longtemps que le permettait l'état clinique de la patiente. La réinsertion a été entreprise alors que la patiente était sous stéroïdes et elle n'a pas entraîné de complications. Résultats: La patiente est restée hémodynamiquement stable et a obtenu son congé après la réinsertion. Les plaies ont granulé et guéri lentement. Les stéroïdes ont été réduits progressivement. Enseignements tirés: À notre connaissance, il s'agit du premier cas rapporté d'une patiente atteinte de pyoderma gangrenosum développé au point d'émergence d'un cathéter d'hémodialyse tunnelisé. Notre patiente a développé un SRIS sans signe d'infection. Nous résumons 11 cas précédents de pyoderma ayant entraîné un SRIS et ayant répondu aux stéroïdes.

Formulation and Evaluation of Novel Thiolated Intra Pocket Periodontal Composite Membrane of Doxycycline.

Localized intra-pocket, retentive, biodegradable, prolonged release thiolated membrane can provide an improved therapeutic efficacy of doxycycline at the site of action with evading off target side effects. To this end, thiolated chitosan-hyaluronic acid composite polymeric complex next-generation of the periodontal membrane was manufactured by solvent casting method. FTIR spectroscopic analysis displayed successful immobilization of thiol groups on the manufactured thiolated periodontal membrane. Moreover, XRD, DSC, AFM and TGA of the membrane confirmed the compatibility of ingredients and modifications in surface chemistry. The thiolated periodontal film was also investigated in terms of thickness, weight uniformity, water-uptake capacity, drug content, pH, entrapment efficiency, lysozymal degradation and release patterns. Also, mucoadhesion profile was explored on gingival mucosa. The immobilized thiol groups on thiolated chitosan and thiolated hyaluronate were found to be 168 ± 11 µM/g (mean ± SD, n = 3) and 189 ± 8 µM/g (mean ± SD, n = 3) respectively. Swelling capacity of the thiolated periodontal membrane was significantly ∼2-fold higher (p < 0.05) as compared to unmodified membrane. The obtained thiolated membrane depicted 3 -old higher mucoadhesive features as compared to the un-modified membrane. In vitro release kinetics indicated approximately more than 80% prolonged release within 7 days. Mechanical strength of the Thiolated bandage was also significantly ∼2-fold higher (p < 0.05) as compared to unmodified membrane. Ex-vivo retention study revealed enhanced retention of thiolated membrane as compared to unmodified membrane. In-vitro antimicrobial studies demonstrated that thiolated membrane could efficiently kill Porphyromonas gingivalis cells as compared to the native membrane. Moreover, ex-vivo biodegradation results indicated that 90% of the thiolated membrane was biodegradable in 28 days. Based on these findings, thiolated next-generation of the periodontal membrane seems to be promising for periodontitis therapy.

Radiological Mean Age of Fusion of Medial End of the Clavicle: AParameter of Age.

OBJECTIVE: To determine the mean age of fusion of medial end of clavicle by radiography. STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: Departments of Forensic Medicine, Dow Medical College and Ziauddin University, Karachi, from June 2010 to May 2011. METHODOLOGY: The subjects for this study were selected from various government colleges of Karachi. The subjects were analyzed for age and further confirmation was done by interviews where birth records and other physical parameters of age were also assessed. X-rays chest PA view was taken focusing on the medial end of clavicle; and were examined by a consultant radiologist and complete fusion of the medial end was noted. P-value less than 0.05 was considered significant. RESULTS: The mean age of fusion of medial end of the clavicle was found to be 21 ±1.43 years. Significant difference was observed in male to female age of fusion 21.14 ±1.41 years versus 20.65 ±1.94 years (p > 0.05). Similarly, statistically significant differences were observed between lower to middle income class and higher income class of all society. No difference was observed among various ethnic groups. CONCLUSION: Socio-economic factors, such as diet and nutrition, directly affect bone growth and hence bones' age. The results of fusion of the medial end of the clavicle are not affected by ethnicity; however, it is significantly affected by gender. More studies should be conducted in various parts of the country to make a natural standard in setting up uniform criteria for assessing age at or above 21 years.

Two interesting cases of EEC syndrome.

AIM: To report two cases of EEC syndrome with oral involvement to highlight the fact that the dental surgeon may be among the first to recognise the condition. INTRODUCTION: The EEC syndrome, a rare congenital syndrome is characterised by ectodermal dysplasia, distal limb anomaly, cleft lip and palate and lachrymal duct anomalies although the term oligosymptomatic EEC syndrome has been suggested for cases in which ectrodactyly may be absent and that such cases should not be deprived of the EEC syndrome diagnosis. It is usually inherited as an autosomal dominant trait with variable expressivity and penetrance and all these features rarely coexist in a single individual. CONCLUSION: Both our cases had all three characteristic features of the EEC syndrome. Other syndromes with overlapping features such as the Rapp-Hodgkin syndrome and the AEC syndrome should be considered in the differential diagnosis of incomplete forms of EEC syndrome. CLINICAL SIGNIFICANCE: It is important to follow an interdisciplinary approach to attain the greatest degree of success possible in the treatment of such cases.

Unusually large sialolith of Wharton's duct.

The formation of calcific concretions in the salivary duct or glands is a common disorder, especially in the submandibular glands. Most of the salivary calculi are small in size, in contrast to those that reach several centimeters, which are reported as megaliths or giant calculi in the literature. They may occur in any of the salivary gland ducts but are most common in Wharton's duct and the submandibular gland. This report presents clinical and radiographical sign of an unusually large sialolith. There was painless swelling on the floor of the edentulous mouth and patient was unaware of it. Radiographical examination revealed large irregular radio-opaque mass superimposed on right canine and premolar areas. This case report describes a patient presenting with an unusually large submandibular gland duct sialolith, the subsequent patient management, the aetiology, diagnosis and its treatment.