RESUMEN
With skin lesions that have failed previous treatments, consideration for an atypical mycobacteria, specifically Mycobacterium marinum, infection should be suspected. Importance of the history cannot be stressed as this is a clue that the patient may have been inoculated and infected in the field environment. A marine with chronic right knee plaque for 3 yr that first appeared after a field exercise at The Basic School but worsened despite treatment with clindamycin, TMP-SMX, and incision and drainage in 2012. Examination revealed a 4 × 4 cm pink, pearly, scaly plaque with scabbing. Deroofing caused puncta to bleed and suppurate. Empiric therapy with doxycycline topical fluocinonide were initiated. Histopathological findings showed dermal fibrosis, granulomatous inflammation, and overlying epidermal inflammation and hyperplasia. Sections also revealed scattered admixed non-necrotizing granulomata. Initial stains, tissue and wound cultures were negative. Acid-fast bacilli broth and smear culture with growth after 4 wk, growing M. marinum. Doxycycline was continued for 2 more months. Mycobacterium marinum is a nontuberculous mycobacterium responsible for skin infections. Sources of infections usually are non-chlorinated water. Infections are rare, an estimated annual incidence of 0.27 cases per 100,000 patients, within the USA and do not cause significant morbidity in immunocompetent patients. Initial M. marinum infections can be mistaken as methicillin resistant Staph aureus infections in the active duty population. If the infection recurs or does not resolve with methicillin resistant Staph aureus-targeted antibiotics, consider cultures specific to acid-fast bacilli and keep in the differential until long term culture results are obtained.
Asunto(s)
Granuloma/etiología , Rodilla/anomalías , Personal Militar , Infecciones por Mycobacterium no Tuberculosas/diagnóstico , Adulto , Antibacterianos/uso terapéutico , Clindamicina/uso terapéutico , Doxiciclina/uso terapéutico , Humanos , Traumatismos de la Rodilla/complicaciones , Masculino , Infecciones por Mycobacterium no Tuberculosas/etiología , Mycobacterium marinum/patogenicidad , EnseñanzaRESUMEN
Intradermal nodular fasciitis is a rare but not extraordinary pathological finding with approximately 100 cases reported since originally described in 1990. Intradermal proliferative fasciitis, however, has only been reported twice and both arose in the postauricular region. Herein, we report a third case of intradermal proliferative fasciitis and the first to occur on the finger. This case was also unusual in its slow growth, and complete lack of smooth muscle actin expression that has only been reported once before.
Asunto(s)
Fascitis/patología , Dedos/patología , Femenino , Humanos , Persona de Mediana EdadRESUMEN
Lymphangioma circumscriptum remains a challenging entity to treat given anatomic considerations and a significant tendency for recurrence regardless of the modality selected. Surgical excision offers the greatest potential for definitive management but is often beset by procedural morbidity and suboptimal cosmetic outcomes. A range of palliative options have been reported for the treatment of lymphangioma circumscriptum, with varying degrees of associated efficacy and morbidity. This report describes the novel use of fractional carbon dioxide laser ablation for the treatment of lymphangioma circumscriptum, with promising cosmetic results and durable symptomatic relief.
Asunto(s)
Neoplasias de Cabeza y Cuello/cirugía , Terapia por Láser/métodos , Láseres de Gas , Linfangioma/cirugía , Neoplasias Cutáneas/cirugía , Niño , Humanos , Masculino , Resultado del TratamientoRESUMEN
OBJECTIVES: Coronary heart disease (CHD) is the number one cause of death in adults in the industrialized world, and several large studies show that aspirin is helpful for the primary prevention of this disease. Unfortunately, few physicians are aware of its benefit, resulting in the underutilization of aspirin for the primary prevention of CHD. The purpose of this study was to demonstrate the underuse of aspirin for the primary prevention of CHD, and to improve appropriate utilization by implementing an easy-to-use clinic tool that quickly estimates a patient's risk. PATIENTS AND METHODS: This is a retrospective cohort analysis conducted in the Internal Medicine Clinic in the Naval Medical Center in San Diego, California. Random samples of 494 patients before and 593 after intervention who were followed in the Internal Medicine Clinic were screened. Inclusion criteria were a 10-year risk of myocardial infarction or coronary death of more than 10%, or diabetes with one other cardiac risk factor. A poster was placed in each clinic examination room showing the Framingham Risk Score, the indications for aspirin use, and common contraindications to assist physicians in determining if a patient warranted aspirin for primary prevention of CHD. A physician documented regular use of aspirin, 81 to 325 mg per day. RESULTS: Age and sex demographics were similar between the two measurement groups. Diabetics comprised a significantly greater percentage of patients in the postintervention group. There was a trend toward increase in utilization of aspirin from 63.5% to 72.8% (P = 0.054) after our intervention. In subgroup analysis, significant improvement in appropriate aspirin use was found amongst males (P = 0.01) and nondiabetics (P = 0.02). CONCLUSION: Aspirin has proven beneficial in the primary prevention of CHD, but is clearly underutilized in this role. By implementing the Framingham Risk Score to streamline the decision process, appropriate utilization can be improved, and in turn, cardiac events can be reduced and patients can benefit.