Risk Factors Associated With Invasive Fungal Infections in Kidney Transplant Patients.

BACKGROUND: Kidney transplant recipients are at increased risk for developing invasive fungal infections (IFI). We queried the United States Renal Data System (USRDS) for risk factors for IFI in these patients. METHODS: Patients who underwent a kidney transplant between 2005 and 2008 were queried for an IFI diagnosis using ICD-9 codes. An IFI was defined as at least one documented diagnosis from one of the following: (1) Candida (candidemia); (2) Histoplasmosis; (3) Aspergillosis; (4) Cryptococcosis; (5) "Other" mycoses. Potential risk factors included demographics, certain comorbidities and immunosuppressive medications. To examine the relative risk (RR), simple bivariate models were used, followed by a comprehensive full model to estimate the adjusted RR (aRR). RESULTS: Of 57,188 kidney transplant patients, 1,218 had 1,343 IFI diagnoses, with a median time to infection of 495 days. "Other" mycoses accounted for the most IFI diagnoses (37%), followed by aspergillosis (22%). The risk for any IFI was increased with age ≥65 years. Diabetes (aRR = 1.71), bacterial pneumonia (aRR = 1.62) and UTI (aRR = 1.34) were the top 3 clinical risk factors for infection. Each of the IFI groups was also associated with individual risk factors. Therapy with mycophenolate mofetil was associated with a decreased risk of candidemia. CONCLUSIONS: Risk factors for IFI in renal transplant patients include demographic, medication-associated and clinical data, as well as organism-specific factors. These results offer an extensive clinical profile of risk for IFI, and may thus help inform the diagnosis and presumptive therapy of invasive fungal infections in renal transplant recipients.

Mortality risk after herpes zoster infection in end-stage renal disease patients.

BACKGROUND: End-stage renal disease (ESRD) patients have increased risk of developing herpes zoster (zoster) compared with the general population, but mortality risk is unknown. We assessed the risk of mortality in hospitalized ESRD patients with a diagnosis of zoster from the inpatient hospital files (as opposed to outpatient records) of the United States Renal Data System. METHODS: This study analyzed incident ESRD patients from 2006 to 2009. Based on an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code of zoster infection, we determined 2-year mortality following an inpatient diagnosis. Cox proportional hazards models were used to examine the association of mortality and zoster, when controlling for demographic and other clinical risk factors. RESULTS: Zoster was diagnosed in 2784 patients, 51% of whom died within 2 years, with a mean time to death of 8.1 months. Patients who died were more likely to be white and older, score higher on the Charlson Comorbidity Index (CCI) and have other clinical diagnoses besides CCI. Increased risk of death within 2 years was associated with older age (adjusted hazard ratio 1.03), malnutrition (1.31), bacteremia/septicemia (1.16) and increasing CCI (1.10). Zoster vaccine was administered to 27 patients, but the small number precluded analysis of its impact. CONCLUSIONS: Mortality in ESRD patients with an inpatient zoster diagnosis is increased with older age and higher severity of clinical comorbidities. The role of zoster vaccination on mortality in this population remains to be defined.

Photocontact Dermatitis and Its Clinical Mimics: an Overview for the Allergist.

Photo-contact dermatitis (PCD) describes the adverse cutaneous reaction that occurs in some patients as a result of simultaneous exposure to a contactant and to light. PCD can be subdivided into photo-allergic and photo-irritant dermatitis depending on whether the contactant respectively invokes an allergic or irritant reaction. Photo-irritant reactions are commonly caused by plants, psoralens, and medications taken internally, whereas photo-allergic reactions are commonly caused by sunscreens and topical nonsteroidal anti-inflammatory medications. The work-up of photo-contact dermatitis includes a thorough history and physical exam augmented by patch and/or photopatch testing, as the cornerstone of treatment for PCD is identification and avoidance of the irritating or allergenic chemical. Photo-contact dermatitis has the potential to significantly impact quality of life, so an informed approach to diagnosis and management is critical. Clinical mimics of PCD include polymorphic light eruption, solar urticaria, actinic prurigo, hydroa vacciniforme, cutaneous porphyrias, and systemic disorders with photosensitivity such as lupus and dermatomyositis. Herein, we review the clinical presentation, differential diagnosis (including the clinical mimics mentioned above), pathogenic mechanisms, diagnostic testing, and therapeutic considerations for PCD.

Assessment of melanoma follow-up trends in Medicare patients: a large scale, multi-regional analysis.

BACKGROUND: Research on patient follow-up compliance after a diagnosis of melanoma has been limited. OBJECTIVE: To assess the timelines for follow-up among patients who are diagnosed with melanoma and to assess the socioeconomic and provider factors which influence follow-up adherence. METHODS: A retrospective, population-based study using nationally representative data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database was conducted to evaluate 10,813 patients who were diagnosed with melanoma from 2005-2013. RESULTS: We found that 97% of the individuals with melanoma had at least one follow-up visit, with 80.5% having their first follow-up visit within the first 6 months and 88.6% having their first follow-up visit within 12 months. Patients who had a dermatologist as the diagnosing provider were significantly more likely to follow up. Additionally, patients who returned were more likely to live in a community with a higher socioeconomic status. LIMITATIONS: Applicability of the data to a non-Medicare population and confounding variables such as co-morbid conditions are limitations. CONCLUSIONS: The majority of patients diagnosed with melanoma follow up with a provider within one year. However, socioeconomic and provider factors play important roles in influencing patient return visits.

Photodermatitis for the Allergist.

PURPOSE OF REVIEW: The photodermatoses represent a group of disorders of sensitivity to light that continue to pose difficulties in diagnosis and management. Photodermatoses are of interest to allergists because many photosensitive skin disorders have immunologic underpinnings, and patients often present to clinic complaining of "allergy" to the sun. We provide a concise reference for allergists on the clinical recognition and management of photodermatitis. RECENT FINDINGS: New developments in the understanding of immunomodulatory effects of light have demonstrated normally immunosuppressive responses in the skin to light exposure, and a blunted immunosuppressive response in the pathogenesis of many photodermatoses. Vitamin D plays an important role in immunomodulation and itself may be affected by photodermatoses due to the impact of photoprotective treatment strategies on circulating vitamin D levels. The elucidation of the immunological basis of many photodermatoses may provide guidance for developing new treatment modalities. Further research is necessary to determine the optimal management of vitamin D metabolism in patients with photodermatoses.

Vulvar Asymmetry Due to Silicone Migration and Granulomatous Immune Response Following Injection for Buttock Augmentation.

A 34-year-old woman was referred to the authors' dermatology clinic for evaluation of right labial swelling and dyspareunia. Her symptoms began after receiving a liquid silicone injection into the buttocks at a cosmetic plastic surgery clinic that was operating illegally by an unlicensed provider. A single prior debulking surgery had produced only temporary relief of symptoms, and the swelling returned. Work-up including magnetic resonance imaging and skin biopsy revealed migration of the injected silicone from her buttock to the subcutaneous tissue of the right labia majora, with an associated granulomatous immune response to the silicone. To the authors' knowledge, the extent of contiguous soft tissue involvement shown in this case has not yet been reported in the medical literature, nor has the finding of migration from the buttocks to the vulvar tissues to produce such dramatic asymmetry. Treatment with intralesional steroids and minocycline was initiated with improvement noted at one-month follow-up. Large volume and adulterated silicone injections are associated with a host of complications, including silicone migration and granuloma formation. No consensus for treatment exists, but attempted therapies have included surgery, local steroid injections, systemic steroids, tetracycline antibiotics, and other immune modulators. Treatment must be tailored to the individual case, considering the patient's preferences and medical history.

Compounded Topical Analgesics for Chronic Pain.

Analgesic medications compounded for topical use are gaining popularity for the management of chronic pain. The advantages of topical pain medications include reduction of systemic adverse effects, improved patient acceptance, few drug interactions, ease of dose determination, avoidance of first-pass metabolism, and direct access to the target site. Compounded topical medications typically use a mixture of 3 or more single medications to achieve multiple complementary effects at lower doses of each individual medication. Herein, we review the mechanisms, adverse effects, and evidence for some of the most commonly used medications in topical compounds for pain management. Because more topical medications are used for chronic pain, dermatologists can expect an increase in irritant and allergic contact dermatitis related to these medications.

Biomedical and Market Issues Surrounding the Advent of Biosimilars.

As the patents associated with the biologics are set to expire in the near future, a new type of therapy appears on the horizon, and it is quite similar to the biologics. This commentary examines the biomedical and market issues surrounding the advent of biosimilars.

Primary cutaneous zygomycosis secondary to minor trauma in an immunocompromised pediatric patient: a case report.

Zygomycosis is an opportunistic infection generally found in immunocompromised individuals. Herein we present a pediatric patient with primary cutaneous mucormycosis that developed at a site of trauma. Diagnosis and treatment are discussed.