ABSTRACT
Streptococcal toxic shock syndrome is a serious complication of group A Streptococcus infection with a high mortality rate. Rapid detection, early intensive care support, and surgical management are paramount in treating these patients. We present a case of a 65-year-old male, with a documented medical history of hypertension, type 2 diabetes mellitus, and peripheral arterial disease. The patient was evaluated in the emergency department with a chief complaint of pain, swelling in his left leg, and fever. Physical examination showed tachycardia, hypotension, and clear inflammatory signs in the left leg. After initial clinical and laboratory evaluation, the patient was admitted with a diagnosis of cellulitis and urinary tract infection. He presented progressive worsening with multi-organ dysfunction, requiring vasopressor support, invasive mechanical ventilation, and renal replacement therapy. Streptococcus pyogenes was isolated in blood cultures, and a streptococcal toxic shock syndrome was considered. Appropriate antibiotic therapy, immunoglobulins, hemoperfusion, and corticosteroid therapy were administered, with clinical improvement. During hospitalization, there was a progressive improvement in the skin lesion. Once clinically stabilized the patient was discharged with follow-up. The case presented shows the rapid evolution of cutaneous streptococcal infection with multiorgan dysfunction. Although these types of infections have an associated high mortality rate, this patient survived. The use of immunoglobulin and hemoperfusion technique, in this case, might have contributed to this positive outcome. Therefore, we highlight the need for high suspicion of this syndrome, especially in diabetic patients presenting with skin lesions. Once the diagnosis is established, these infections require close surveillance and rapid and intensive treatment.
ABSTRACT
Spontaneous tongue hematoma is a known rare adverse side effect associated with warfarin therapy. There is a long list of drug-to-drug interactions with warfarin that may contribute to a rise in international normalized ratio (INR) levels, increasing the risk of bleeding. We present a case of an elderly female patient who presented with oral dysphagia and spontaneous oral cavity bleeding while on warfarin therapy. She was found to have tongue hematoma and necrosis. A week prior she started treatment with topical miconazole for oral candidiasis and a few days later topical clarithromycin was added. Treatment given was mainly supportive with intravenous vitamin K, fresh frozen plasma, and aminocaproic acid. Full recovery was achieved. It is our intention to raise awareness of a rare adverse side effect related to warfarin therapy that may have been precipitated with the use of medications known to contribute to INR elevation. As learning points, we emphasize close monitoring of INR levels when using known drug-to-drug interactions with warfarin and also consider replacing warfarin for a direct oral anticoagulant if no contraindication is present.
ABSTRACT
Calcinosis cutis is a rare and potentially disabling condition characterized by calcium deposition in soft tissues. When associated with autoimmune connective tissue diseases, calcinosis cutis is classified as Dystrophic Calcinosis Cutis (DCC), being its occurrence in systemic lupus erythematosus (SLE) patients fairly uncommon. We report a case of DCC in a 49 years old woman with eleven years evolution SLE that presented with a two years history of multiple painful skin lesions, some of them ulcerated and exhibiting a chalky white-yellow floor, in both hands, forearms, thighs, buttocks, abdomen and left breast. The pelvic X-ray showed soft tissue calcifications and the skin biopsy confirmed the diagnosis of DCC. The patient was treated with diltiazem 240mg/day and a significant regression of the lesions and associated pain was observed. Dystrophic calcinosis cutis is often a painful and disrupting condition in which timely diagnosis and treatment may be quite challenging.
