RESUMO
Serratia marcescens is a gram-negative bacterium found commonly in water and soil. Initially thought to be non-pathogenic, it is now recognised as an important cause of nosocomial and opportunistic infections. Skin infections are rare, but cases of S. marcescens causing ulcers, abscesses and necrotizing fasciitis have been reported. We report an unusual cutaneous presentation of S. marcescens in an immunosuppressed patient. A 77-year-old man under review for non-melanoma skin cancer in the context of a previous cardiac transplant, presented with an asymptomatic scalp eruption. Immunosuppressive medications included ciclosporin 90 mg twice daily (2.5 mg/kg/day) and mycophenolate mofetil 1 g twice daily. Physical examination revealed well-defined annular and polycyclic patches with brownish crusting across his scalp. Bacterial culture demonstrated a heavy growth of Staphylococcus aureus sensitive to flucloxacillin. The patient was treated with 7 days of flucloxacillin 500 mg four times daily. Despite this, the eruption extended. Skin biopsy demonstrated epidermal spongiosis, florid dermal inflammatory cell infiltrate and abundant bacteria and neutrophils in the parakeratotic crust. Fungal stains were negative as was direct immunofluorescence. Repeat culture demonstrated heavy growth of S. marcescens sensitive to ciprofloxacin. The patient was treated with 10 days of oral ciprofloxacin 500 mg twice daily along with 1% hydrogen peroxide cream topically with significant clinical improvement. Microbiological review indicated that a gram-negative organism was present in the initial scalp swab. In addition, S. marcescens had been detected previously on a skin swab from a recent transient eruption on the torso. Further, a heavy growth of a coliform bacillus was demonstrated in a similar eruption on the chest in 2013. It was concluded that the patient was likely colonised with S. marcescens which appeared to have caused recurrent superficial skin infections over several years. We report this case to highlight an unusual clinical presentation of cutaneous S. marcescens infection. This should be considered in the differential diagnosis of skin eruptions in immunocompromised patients. Clinical information detailing a patient's immunosuppressed state must be supplied on microbiology requests to allow accurate interpretation of results, and consideration of organisms which may otherwise be overlooked or considered contaminants.
RESUMO
OBJECTIVE: Flexible sigmoidoscopy reduces the incidence of colonic cancer through the detection and removal of premalignant adenomas. However, the efficacy of the procedure is variable. The aim of the present study was to examine factors associated with the efficacy of detecting polyps during flexible sigmoidoscopy. DESIGN AND PATIENTS: Retrospective observational cohort study of all individuals undergoing routine flexible sigmoidoscopy in NHS Greater Glasgow and Clyde from January 2013 to January 2016. RESULTS: A total of 7713 patients were included. Median age was 52 years and 50% were male. Polyps were detected in 1172 (13%) patients. On multivariate analysis, increasing age (OR 1.020 (1.016-1.023) p<0.001), male sex (OR 1.23 (1.10-1.38) p<0.001) and the use of any bowel preparation (OR 3.55 (1.47-8.57) p<0.001) were associated with increasing numbers of polyps being detected. There was no significant difference in the number of polyps found in patients who had received an oral laxative preparation compared with an enema (OR 3.81 (1.57-9.22) vs 3.45 (1.43-8.34)), or in those who received sedation versus those who had not (OR 1.00 vs 1.04 (0.91-1.17) p=0.591). Furthermore, the highest number of polyps was found when the sigmoidoscope was inserted to the descending colon (OR 1.30 (1.04-1.63)). CONCLUSIONS: Increasing age, male sex and the utilisation of any bowel preparation were associated with an increased polyp detection rate. However, the use of sedation or oral laxative preparation appears to confer no additional benefit. In addition, the results indicate that insertion to the descending colon optimises the efficacy of flexible sigmoidoscopy polyp detection.
