Bromelain-Based Enzymatic Debridement Versus Standard of Care in Deep Burn Injuries: A Systematic Review and Meta-Analysis.

Deep burn injuries necessitate effective debridement to promote healing and reduce complications. Traditional surgical debridement is the standard of care; however, it can lead to significant tissue loss, excessive bleeding and delayed healing. Bromelain-based enzymatic debridement offers a potential less invasive alternative that aims to selectively remove necrotic tissue while preserving viable ones. Therefore, this systematic review and meta-analysis comprehensively compares bromelain debridement versus standard care in the management of partial and full-thickness burns. Cochrane Library, Embase, and Medline were searched until May 30th, 2024 for studies comparing bromelain debridement versus standard care. R version 4.4.0 was used to pooled risk ratio and mean difference in a random-effects model. We included seven studies, comprising 484 participants, of whom 238 (49%) were treated with enzymatic debridement. Bromelain significantly reduced time to eschar removal (MD - 7.60 days 95% CI [-9.76, -5.44]; I² = 70%) in comparison with standard care. Additionally, bromelain group presented a significant reduction in the risk of surgical excision (RR 0.17; 95% CI [0.06, 0.47]; I² = 79%) and need for autografts (RR 0.40; 95% CI [0.18, 0.93]; I² = 76%) in comparison with standard group. No differences were found in behalf of time to wound closure (MD -7.64; 95% CI [-18.46]-[3.18]; I2 = 86%), nor in Modified Vancouver Scar Scale (MD -0.36; 95% CI [-0.96]-[0.23]; I2 = 0%). Bromelain-based enzymatic debridement may accelerate eschar removal and reduce the need for surgical excision and autografts, without adversely affecting wound closure time or long-term scar quality.

Osteomielite maxilar associada ao COVID-19: mucormicose ou não? Uma série de casos / Maxillary osteomyelitis associated with COVID-19: mucormycosis or not? A series of cases

Aim: A series of cases have been presented involving the oral cavity focusing on the presentation, diagnosis and treatment of mucormycosis that can form a basis for successful therapy. Background: The management of severe coronavirus disease (COVID-19) in conjunction with comorbidities such as diabetes mellitus, hematological malignancies, organ transplants, and immunosuppression have led to a rise of mucormycosis which is an opportunistic infection. Cases Description: The various forms that have been enlisted till date are rhino-cerebral, rhino-orbital, gastrointestinal, cutaneous, and disseminated mucormycosis. From the dentistry and maxillofacial surgery perspective, the cases depicting extension of mucormycosis into the oral cavity have been less frequently recorded and thus, require a detailed study. The patients that reported to our private practice had non-tender swelling, draining sinuses and mobility of teeth. A similarity was observed in the clinical signs both in osteomyelitis and mucormycosis. Thus, a histopathological examination was used to establish the definitive diagnosis. Conclusion: Mucormycosis is a life threatening pathology that requires intervention by other branches to make an early diagnosis and commence the treatment. The characteristic ulceration or necrosis is often absent in the initial stage and thus, histopathological examination and radiographic assessment are required to formulate a definitive diagnosis. Early intervention is a necessity to avoid morbidity. The treatment involves surgical debridement of the necrotic infected tissue followed by systemic antifungal therapy. Mucormycosis has recently seen a spike in its prevalence, post the second-wave of coronavirus pandemic in India. It was seen commonly in patients with compromised immunity, diabetes mellitus, hematological malignancies, or on corticosteroid therapy. Mucormycosis invading the palate mostly via maxillary sinus has been less frequently described. In the post-COVID era the features associated with mucormycosis involving oral cavity, should warrant a possible differential diagnosis and managed appropriately. (AU)

Objetivo: Apresentar uma série de casos com enfâse na apresentação, diagnóstico e tratamento da mucormicose oral, assim como uma revisão sistemática que sirva como base para estabelecimento de terapias de sucesso. Introdução: A forma severa da infecção por coronavirus (COVID-19) associada a diabetes mellitus, doenças hematológicas malignas, transplante de órgãos e imunossupressão levaram a um aumento das infecções oportunistas de mucormicose. Descrição dos Casos: As diversas apresentações clínicas que foram descritas até o momento são a rinocerebral, rino-orbital, gastrointestinal, cutânea e mucormicose disseminada. No que concerne a odontologia e a cirurgia maxillofacial, os casos que apresentam extensão de mucormicose para cavidade oral tem sido menos reportados e assim requerem mais estudos. Os pacientes que compareceram a nossa clínica apresentavam aumento de volume endurecido, drenagem de fluidos dos seios maxilares e mobilidade dentária. Clinicamente tanto a osteomielite quanto a mucormicose apresentaram-se de forma semelhante. Assim, análise histopatológica foi utilizada para estabelecimento do diagnóstico definitivo. Conclusão: A mucormicose é uma patologia grave que requer intervenção precoce para estabelecimento do tratamento. A ulceração e necrose características usualmente estão ausentes nos estágios iniciais da lesão, assim análise histopatológica e radiográfica são necessárias para o diagnóstico final. Intervenção precoce é necessária para diminuir a morbidade. O tratamento envolve o debridamento cirúrgico da área necrosada seguida de terapia antifúngica sistêmica. Recentemente, houve um aumento nos casos de mucormicose, após a Segunda onda da pandemia de COVID-19 na índia. Os casos acometiam principalmente pacientes imunocomprometidos, com diabetes mellitus, doenças hematológicas malignas e em uso de corticosteróides. A mucormicose invadindo o palato pelos seios maxilares foi raramente descrita. Na era pós-COVID a mucormicose envolvendo a cavidade oral deve entrar no painel de diagnósticos diferenciais para que o tratamento adequado possa ser instituído precocemente.(AU)

The inoculation eschar of Rickettsia parkeri rickettsiosis in Brazil: Importance and cautions.

Two well characterized tick-borne rickettsioses occur in Brazil. Rickettsia rickettsii caused spotted-fever, transmitted by Amblyomma sculptum and Amblyomma aureolatum, is a severe disease with a high case-fatality rate in the southeastern region of the country. Rickettsia parkeri strain Atlantic rainforest infections transmitted by adult Amblyomma ovale ticks cause a milder non-lethal febrile disease with an eschar (necrosis) at the tick bite site. Clinical diagnosis of rickettsiosis is challenging, particularly during the early stages of the illness when signs and symptoms are non-specific. Since eschar at the tick bite site has emerged as the main clinical feature of mild R. parkeri infections and used to differentiate it from severe R. rickettsii infection, its proper recognition, distinction from other tick bite lesions, and boundaries as a clinical tool must be highlighted. Of importance, eschars induced by Rickettsia must be differentiated from dermatoses caused by other tick-borne skin infections as well from lesions caused by the tick bite itself. We herein highlight information on eschar in rickettsial diseases in Brazil and discuss the need for further research on its clinical relevance and application in the diagnosis of spotted fever caused by R. parkeri strain Atlantic rainforest. In particular, we draw attention to diagnosis of other febrile diseases in the presence of concomitant tick bites.

A new focus of spotted fever caused by Rickettsia parkeri in Brazil

ABSTRACT Spotted fever (SF) is a tick-borne zoonosis caused by bacteria of the genus Rickettsia . The disease varies in severity from mild clinical forms to severe cases. In Brazil, Rickettsia rickettsii SF is the most serious rickettsiosis and can result in death if not diagnosed and treated at the onset of symptoms. The SF mild form is caused by Rickettsia parkeri strain Atlantic Rainforest, and this etiological agent has been reported in the South, Southeast and Northeast regions of the country, in areas of preserved or little antropized Atlantic Rainforest. Amblyomma ovale is the proven vector and dogs are the hosts associated with the bioagent cycle. During a SF case investigation in Paraty municipality, Rio de Janeiro State, an Atlantic Rainforest biome area in Southeastern Brazil, the human pathogen R. parkeri strain Atlantic Rainforest was detected by PCR in a sample of human skin inoculation eschar and in a female A. ovale tick collected from a dog. These results expand the known area of occurrence of this mild form rickettsiosis in Brazil. In addition, the results of the present study indicate the importance of implementing programs to control canine ectoparasites and to raise awareness of the risks of infection, signs and symptoms of SF caused by R. parkeri strain Atlantic Rainforest.

Linfadenopatía transmitida por garrapata. Un caso pediátrico de rickettsiosis en atención primaria / Lymphadenopathy transmitted by tick. A pediatric case of rickettsiosis in primary care

La entidad llamada tick-borne lymphadenopathy, también conocida como dermacentor-borne necrosis eritema lymphadenopathy, se incluye dentro del diagnóstico diferencial de enfermedades transmitidas por garrapatas, que han aumentado considerablemente en los últimos años debido a una mayor observación clínica-epidemiológica y mejoría diagnóstica. Es una zoonosis causada por Rickettsia slovaca y transmitida por la picadura de la garrapata Dermacentor marginatus. Los pacientes afectados tienen una escara necrótica rodeada de un halo eritematoso en el cuero cabelludo y adenopatías regionales dolorosas. Se presenta a un varón de siete años que mostró, tras la extracción de una garrapata, una escara necrótica en el cuero cabelludo, con adenopatías y febrícula. La reacción en cadena de la polimerasa y el cultivo de la lesión confirmaron la presencia de Rickettsia slovaca. El paciente recibió azitromicina oral con buena respuesta. En Atención Primaria, es importante el seguimiento de las picaduras de garrapatas para detectar posibles enfermedades transmitidas por estas.

The entity called tick-borne lymphadenopathy, also known as dermacentor-borne necrosis eritema lymphadenopathy, is included in the differential diagnosis of diseases transmitted by ticks, which have increased considerably in recent years due to greater clinical-epidemiological observation and diagnostic improvement. It is a zoonosis caused by Rickettsia slovaca and transmitted by the bite of the Dermacentor marginatus tick. Affected patients have a necrotic eschar surrounded by an erythematous halo in the scalp, as well as painful regional lymphadenopathy. Linfadenopatía transmitida por garrapata. Un caso pediátrico de rickettsiosis en atención primaria Lymphadenopathy transmitted by tick. A pediatric case of rickettsiosis in primary care We present a seven-year-old male who shows, after the extraction of a tick, a necrotic eschar on the scalp, accompanied by lymphadenopathy and low-grade fever. The study of polymerase chain reaction and culture of the lesion confirm the presence of Rickettsia slovaca. The patient received oral azithromycin with a good response. In Primary Care, it is important to monitor the tick bites, to detect possible diseases transmitted by them.

[Lymphadenopathy transmitted by tick. A pediatric case of rickettsiosis in primary care]. / Linfadenopatía transmitida por garrapata. Un caso pediátrico de rickettsiosis en atención primaria.

The entity called tick-borne lymphadenopathy, also known as dermacentor-borne necrosis eritema lymphadenopathy, is included in the differential diagnosis of diseases transmitted by ticks, which have increased considerably in recent years due to greater clinical-epidemiological observation and diagnostic improvement. It is a zoonosis caused by Rickettsia slovaca and transmitted by the bite of the Dermacentor marginatus tick. Affected patients have a necrotic eschar surrounded by an erythematous halo in the scalp, as well as painful regional lymphadenopathy. We present a seven-year-old male who shows, after the extraction of a tick, a necrotic eschar on the scalp, accompanied by lymphadenopathy and low-grade fever. The study of polymerase chain reaction and culture of the lesion confirm the presence of Rickettsia slovaca. The patient received oral azithromycin with a good response. In Primary Care, it is important to monitor the tick bites, to detect possible diseases transmitted by them.

La entidad llamada tick-borne lymphadenopathy, también conocida como dermacentor-borne necrosis eritema lymphadenopathy, se incluye dentro del diagnóstico diferencial de enfermedades transmitidas por garrapatas, que han aumentado considerablemente en los últimos años debido a una mayor observación clínica-epidemiológica y mejoría diagnóstica. Es una zoonosis causada por Rickettsia slovaca y transmitida por la picadura de la garrapata Dermacentor marginatus. Los pacientes afectados tienen una escara necrótica rodeada de un halo eritematoso en el cuero cabelludo y adenopatías regionales dolorosas. Se presenta a un varón de siete años que mostró, tras la extracción de una garrapata, una escara necrótica en el cuero cabelludo, con adenopatías y febrícula. La reacción en cadena de la polimerasa y el cultivo de la lesión confirmaron la presencia de Rickettsia slovaca. El paciente recibió azitromicina oral con buena respuesta. En Atención Primaria, es importante el seguimiento de las picaduras de garrapatas para detectar posibles enfermedades transmitidas por estas.

A human case of spotted fever caused by Rickettsia parkeri strain Atlantic rainforest and its association to the tick Amblyomma ovale.

BACKGROUND: Rickettsia parkeri strain Atlantic rainforest has emerged in Brazil during the last 10 years, with three laboratory-confirmed human cases. While these cases were epidemiologically associated with the tick Amblyomma ovale, in none of them the tick specimens that bit the patients could be identified. RESULTS: We report a clinical case of spotted fever rickettsiosis that was acquired in an Atlantic forest area in Bahia state, northeast Brazil. The case was determined to be caused by R. parkeri strain Atlantic rainforest, based on molecular analysis of the crust removed from the tick bite site (inoculation eschar) of the patients' skin. DNA extracted from the crust yielded partial sequences of three rickettsial genes (gltA, ompA and ompB), which were 99-100% identical to R. parkeri strain Atlantic rainforest. The tick specimen that was attached to patient skin was identified as a female of A. ovale. CONCLUSIONS: We report the fourth confirmed case of spotted fever rickettsiosis caused by R. parkeri strain Atlantic rainforest, providing to our knowledge for the first time, direct evidence of R. parkeri strain Atlantic rainforest transmission by A. ovale.

An autochthonous confirmed case of Rickettsia parkeri rickettsiosis in Uruguay.

Rickettsia parkeri, a member of the spotted fever group (SFG) rickettsiae, was first confirmed as an etiological agent of human rickettsiosis in 2004. Nearly all cases are characterized by an inoculation eschar, and no fatalities have been reported. In Uruguay, probable human cases of R. parkeri infection (confused initially with R. conorii infection) have been described since 1990 using the clinical name "cutaneous-ganglionar" rickettsiosis. This is the only tick-borne rickettsiosis reported in the country. A single case of R. parkeri rickettsiosis has been confirmed by molecular and serological testing in a Spanish traveler returning from Uruguay. We report the first autochthonous human R. parkeri infection, confirmed by molecular testing in Uruguay.

Syndromic classification of rickettsioses: an approach for clinical practice.

Rickettsioses share common clinical manifestations, such as fever, malaise, exanthema, the presence or absence of an inoculation eschar, and lymphadenopathy. Some of these manifestations can be suggestive of certain species of Rickettsia infection. Nevertheless none of these manifestations are pathognomonic, and direct diagnostic methods to confirm the involved species are always required. A syndrome is a set of signs and symptoms that characterizes a disease with many etiologies or causes. This situation is applicable to rickettsioses, where different species can cause similar clinical presentations. We propose a syndromic classification for these diseases: exanthematic rickettsiosis syndrome with a low probability of inoculation eschar and rickettsiosis syndrome with a probability of inoculation eschar and their variants. In doing so, we take into account the clinical manifestations, the geographic origin, and the possible vector involved, in order to provide a guide for physicians of the most probable etiological agent.