An unusual case of Escherichia coli cellulitis and bacteremia in an immunocompetent patient.

Cellulitis secondary to Escherichia coli (E. coli) is a rare phenomenon, particularly in an immunocompetent patient. We report an unusual case of an immunocompetent 84-year-old female presenting with E.coli bacteremia and E. coli cellulitis in the right lower leg. We postulate that bacterial translocation from the gastrointestinal tract to the bloodstream is the most likely source of E. coli infection. Whilst a common condition, cellulitis can pose a diagnostic and therapeutic challenge when a causative organism is not identified. Thorough investigation and consideration of atypical organisms such as E.coli are essential to permit targeted antimicrobial therapy and prevent patient deterioration.

Intravenous immunoglobulin treatment for refractory pyoderma gangrenosum.

BACKGROUND: Intravenous immunoglobulins (IVIG) have been increasingly used for various inflammatory dermatoses with success. Small case series and case reports suggest a role for IVIG in the management of refractory pyoderma gangrenosum (PG). OBJECTIVE: The objective was to study the characteristics of PG patients treated with IVIG and the efficacy and safety of IVIG for patients with refractory PG. METHODS: An analysis was performed of all patients with PG treated with IVIG from 2012 to 2022 at an Australian tertiary hospital seeing a high volume of PG patients. RESULTS: We identified 12 patients, 9 females and 3 males, with median age of 61 years (29-77) at IVIG commencement. All patients were taking systemic corticosteroid therapy prior to IVIG treatment, and all had been treated with a steroid-sparing agent-including ten patients who had been treated with a biologic agent. IVIG was used with corticosteroids in one patient, concurrently with a steroid-sparing agent in nine patients and with a biologic agent in eight patients. Eleven patients demonstrated treatment response to IVIG-six with excellent response and five with good response. Three patients had complete healing of their most active ulcer. One patient did not respond to IVIG. Nine patients were able to wean their prednisolone dose and one patient was able to cease prednisolone. Four adverse events were recorded, and only one patient had to cease treatment due to aseptic meningitis and headaches. CONCLUSION: Our experience suggests that IVIG may be an efficacious treatment for patients with refractory PG due to its pleiotropic and immunomodulatory effects, particularly for patients with malignancy or other systemic conditions where high-dose immunosuppressive agents are contraindicated.

VEXAS syndrome: A dermatological perspective.

VEXAS (Vacuoles, E1 enzyme, X-linked, autoinflammatory and somatic mutation) syndrome is a genetically defined disorder identified in 2020, describing patients with inflammatory syndromes associated with haematological dysfunction. It is a severe, treatment-resistant condition, with estimated mortality between 40% and 63%. A wide range of cutaneous manifestations have been described. Here, we report on two patients with treatment-resistant neutrophilic dermatosis and myelodysplastic syndrome, who were subsequently diagnosed with VEXAS syndrome. Our cases highlight the need for dermatologists' awareness of this novel condition and to initiate early referral to haematologists for appropriate multidisciplinary care.

Preoperative Platelet-to-Lymphocyte Ratio Is Not Associated With Postoperative Atrial Fibrillation.

BACKGROUND: Postoperative atrial fibrillation (POAF) is a common complication after coronary artery bypass grafting (CABG) and is associated with increased short-term and long-term mortality. While the precise etiology of POAF remains unclear, inflammation is a known contributing factor. Preliminary studies have suggested that an elevated preoperative platelet-to-lymphocyte ratio (PLR), an inexpensive and readily available novel inflammatory biomarker, may be associated with increased incidence of POAF after CABG. This study sought to further investigate this hypothesis. METHODS: The study cohort included all patients undergoing isolated CABG, with no prior history of arrhythmia, who were operated on between August 1, 2010, and December 31, 2018, at a major Australian tertiary center (n = 1457). Patients were divided into low (<86) or high (≥86) PLR groups based on an optimal cutoff derived from receiver-operating characteristic curve analysis. The incidence of POAF was then compared. Categorical variables were analyzed using the chi-square test and continuous variables using logistic regression. RESULTS: Of 1457 patients, 495 (34.0%) developed POAF. There was no statistically significant difference in the incidence of POAF between patients in the high-PLR and low-PLR groups (34.8% vs 31.0%; P = .22). Using multivariable logistic regression analysis, high PLR was not independently associated with POAF (odds ratio, 1.04; P = .78). CONCLUSIONS: Elevated preoperative PLR is not independently associated with POAF in patients undergoing isolated CABG. The findings of this study differ from those of 2 previous smaller studies.

A radiographic analysis of the abnormal hallux interphalangeus angle range: Considerations for surgeons performing Akin osteotomies.

PURPOSE: This study is aimed to determine the abnormal radiological hallux interphalangeus angle (HIA) range, which can assist surgeons in determining the required bone resection in an Akin osteotomy of the proximal phalanx of the great toe. METHODS: Radiographs of 141 feet were analyzed. The mean HIA and range were calculated. RESULTS: The prevalence of hallux valgus interphalangeus (HVI) deformity was 78% (110/141). The mean HIA was 13.5° ± 4.5° (1.4-24.4). Fifty percent had abnormal HIA values of 10-15°, 40% had values of 15-20°, and 10% had greater than 20°. A large proportion of patients with HVI deformities may need greater than the standard 2-3-mm bone wedge removal during Akin osteotomy. CONCLUSION: The high prevalence and wide range of HVI deformities should alert surgeons to the possibility that greater than 3-mm bone wedge resections may be required. Level of Evidence: Level IV.