Toby Maurer

Randomized, Double-Blind, Placebo-Controlled Trial of Cephalexin for Treatment of Uncomplicated Skin Abscesses in a Population at Risk for Community-Acquired Methicillin-Resistant Staphylococcus aureus Infection

ABSTRACT Empirical use of beta-lactam antibiotics, the preferred agents for treating uncomplicated skin and soft tissue infections, may no longer be appropriate for these infections because of the increasing prevalence of community strains of methicillin-resistant Staphylococcus aureus (MRSA). Retrospective studies, however, suggest that outcomes are good even when beta-lactams are used. We conducted a randomized, double-blind trial of 166 outpatient subjects comparing placebo to cephalexin at 500 mg orally four times for 7 days after incision and drainage of skin and soft tissue abscesses. The primary outcome was clinical cure or failure 7 days after incision and drainage. S. aureus was isolated from 70.4% of abscess cultures. Of the isolates tested 87.8% were MRSA, 93% of which were positive for Panton-Valentine leucocidin genes. Clinical cure rates were 90.5% (95% confidence interval, 0.82 to 0.96) in the 84 placebo recipients and 84.1% (95% confidence interval, 0.74 to 0.91) in the 82 cephalexin recipients (difference in the two proportions, 0.0006; 95% confidence interval, −0.0461 to 0.0472; P = 0.25). The 90.5% cure rate observed in the placebo arm and 84.1% cure rate observed in the cephalexin arm provide strong evidence that antibiotics may be unnecessary after surgical drainage of uncomplicated skin and soft tissue abscesses caused by community strains of MRSA.

Psoriasis and human immunodeficiency virus infection

BACKGROUND Psoriasis associated with human immunodeficiency virus (HIV) infection has been reported to be severe and perhaps associated with decreased survival. OBJECTIVE Our purpose was to document the natural history, response to therapy, and effect of psoriasis and its treatment on survival in HIV-infected patients with psoriasis. METHODS This was an observational cohort study of 50 persons with psoriasis and HIV infection followed up during a 2-year period. RESULTS In one third of the patients the psoriasis appeared before 1978, the year when HIV seroconversion began in San Francisco (group I). In two thirds psoriasis developed after 1978 (group II). Group I had a lower mean age of onset (19 vs 36 years) and more commonly had a family history of psoriasis. Palmoplantar and inverse psoriasis were more common in group II. Severe psoriasis occurred in one fourth of this group (12 of 50 patients). The median survival in this group after diagnosis of acquired immunodeficiency syndrome (AIDS) was 19 months, which is comparable to the median survival for all AIDS patients diagnosed in San Francisco between 1984 and 1990. CONCLUSION Psoriasis in the setting of HIV disease may be mild, moderate, or severe. Standard therapies and zidovudine are effective in management. Survival does not seem to be adversely affected by the presence of psoriasis or its therapy.

HIV-associated psoriasis: pathogenesis, clinical features, and management

Psoriasis is a chronic papulosquamous skin disease that is thought to be a T-cell-mediated autoimmune disorder of keratinocyte proliferation. The association between psoriasis and HIV infection seems paradoxical, but insights into the role of T-cell subsets, autoimmunity, genetic susceptibility, and infections associated with immune dysregulation might clarify our understanding of the pathogenesis of psoriasis with HIV in general. HIV-associated psoriasis can be clinically confusing because several comorbid skin disorders in patients with HIV can mimic psoriasis. Phenotypic variants such as a Reiters syndrome or fulminant erythroderma provide diagnostic clues to underlying immunodeficiency. The management of moderate and severe HIV-associated psoriasis is challenging, although patients typically improve with highly active antiretroviral therapy. Conventional systemic treatments might be contraindicated or need dose adjustment to avoid toxicity. New biological treatments in this setting are promising and warrant further study.

Prevalence of Bartonella Infection among Human Immunodeficiency Virus—Infected Patients with Fever

Bartonella infection can be difficult to diagnose, especially when it manifests as bacteremia, which is usually accompanied by nonspecific symptoms, such as fever. Therefore, we hypothesized that Bartonella infection represents an underrecognized cause of febrile illness. To determine the prevalence of Bartonella infection among patients presenting with fever, we evaluated 382 patients in San Francisco. Overall, 68 patients (18%) had evidence of Bartonella infection detected by culture, indirect fluorescent antibody testing, or polymerase chain reaction (PCR). Twelve patients (3%) had either Bartonella henselae or Bartonella quintana isolated from specimens of blood, tissue, or both or had DNA detected in tissue; all 12 had concomitant human immunodeficiency virus (HIV) infection. Bartonella antibodies were detected in 17% of febrile patients, including 75% of culture-positive or PCR-positive patients. In a nested, matched case-control study aimed at identifying clinical features of febrile illness associated with Bartonella infection, only bacillary angiomatosis and elevated alkaline phosphatase levels were associated with Bartonella infection (P< or =.03 for both). The prevalence of Bartonella infection among patients with late-stage HIV infection and unexplained fever is much greater than has previously been documented.

Hidradenitis Suppurativa and Concomitant Pyoderma Gangrenosum A Case Series and Literature Review

BACKGROUND Hidradenitis suppurativa (HS) and pyoderma gangrenosum (PG) are both rare inflammatory skin conditions that are associated with systemic inflammatory diseases. We performed a retrospective medical chart review of patients with an overlap of HS and PG. OBSERVATIONS We identified 11 cases of PG lesions presenting in patients with HS. Ten of the patients were women, and 9 were obese. All the patients developed HS lesions first, a median of 2.5 years (range, 0-15 years) preceding the appearance of PG lesions. All patients required multiple therapeutic agents because their diseases were often poorly responsive to standard therapies. Two patients received tumor necrosis factor inhibitors; 1 responded to treatment. One patient was treated with anakinra (interleukin-1 receptor antagonist) and had a 75% improvement of her lesions. CONCLUSIONS We have identified a group of patients who have an overlap of PG and HS. Pyoderma gangrenosum can appear at any point after the development of HS and often has a severe, refractory course. We propose that PG and HS may represent variant manifestations of cytokine dysregulation by the innate immune system with common etiology. New therapeutic agents are eagerly sought, and further investigation with regard to interleukin 1 blockade is warranted.

The use of methotrexate for treatment of psoriasis in patients with HIV infection

The use of methotrexate (MTX) has been contraindicated for treatment of severe psoriasis in HIV infection on the basis of six previously reported cases in which MTX appeared to potentiate opportunistic infections and accelerate HIV disease. We describe three HIV-infected patients who were given MTX for severe psoriatic arthritis. In two patients opportunistic infections did not develop. On the basis of survival data, it is not clear that use of MTX adversely affected the natural course of their HIV disease.

Unusual cutaneous lesions in two patients with visceral leishmaniasis and HIV infection.

Two HIV infected patients with visceral leishmaniasis and unusual cutaneous lesions are described. The first patient developed linear brown macules containing Leishmania parasites on the fingers and palms of the hands. This patient never received highly active antiretroviral treatment and the visceral leishmaniasis could not be cured even with liposomal amphotericin. In the second patient, Leishmania parasites were present in a skin biopsy of a fibrous histiocytoma. After completing visceral leishmaniasis treatment, a discrete elevation of one of his tattoos was seen. A biopsy specimen of this tattoo revealed Leishmania amastigotes. In this patient the visceral leishmaniasis was finally cured with meglumine antimoniate, followed by pentacarinat isothianate as maintenance therapy in conjunction with highly active antiretroviral treatment.

Eosinophilic folliculitis : the histologic spectrum

We sought to define the light microscopic features of eosinophilic folliculitis as it occurs in human immunodeficiency virus (HIV)-infected individuals. The histologic findings of 52 biopsies from 50 patients were graded and compared with six biopsies of suppurative folliculitis from HIV-infected individuals. In all patients, clinical examination showed an eruption of pruritic follicular papules, and the folliculocentric nature of the disorder was confirmed histologically. Perifollicular infiltrates of lymphocytes and eosinophils were identified in all study biopsies, and there was also spongiosis of follicular epithelium. The inflammatory reaction was focused at the level of the follicular isthmus and the sebaceous duct. In all biopsies, lymphocytes and/or eosinophils were present within spongiotic follicular epithelium, but intrafollicular neutrophils were rare. Sebaceous glandular inflammation, eosinophilic pustule formation, and follicular rupture were present in less than half of the biopsies. Small numbers of microbes (bacteria, yeast, Demodex) were identified in 25% of the study biopsies in routine or special stains, but the organisms were away from areas of inflammation and were interpreted as nonpathogenic flora. The biopsies of suppurative folliculitis differed in that neutrophils and macrophages predominated in the infiltrate, microorganisms were readily identified in the inflammatory reaction, and the involved follicle was often ruptured. We believe that eosinophilic folliculitis is a unique HIV-associated dermatosis distinguishable from other folliculitides and papular dermatitides by clinical examination and light microscopy. We present our diagnostic approach.

Improving primary care residents' proficiency in the diagnosis of skin cancer.

OBJECTIVE: To determine whether a brief, multicomponent intervention could improve the skin cancer diagnosis and evaluation planning performance of primary care residents to a level equivalent to that of dermatologists.PARTICIPANTS: Fifty-two primary care residents (26 in the control group and 26 in the intervention group) and 13 dermatologists completed a pretest and posttest.DESIGN: A randomized, controlled trial with pretest and posttest measurements of residents’ ability to diagnose and make evaluation plans for lesions indicative of skin cancer.INTERVENTION: The intervention included face-to-face feedback sessions focusing on residents’s performance deficiencies; an interactive seminar including slide presentations, case examples, and live demonstrations; and the Melanoma Prevention Kit including a booklet, magnifying tool, measuring tool, and skin color guide.MEASUREMENTS AND MAIN RESULTS: We compared the abilities of a control and an intervention group of primary care residents, and a group of dermatologists to diagnose and make evaluation plans for six categories of skin lesions including three types of skin cancer—malignant melanoma, squamous cell carcinoma, and basal cell carcinoma. At posttest, both the intervention and control group demonstrated improved performance, with the intervention group revealing significantly larger gains. The intervention group showed greater improvement than the control group across all six diagnostic categories (a gain of 13 percentage points vs 5, p<.05), and in evaluation planning for malignant melanoma (a gain of 46 percentage points vs 36, p<.05) and squamous cell carcinoma (a gain of 42 percentage points vs 21, p<.01). The intervention group performed as well as the dermatologists on five of the six skin cancer diagnosis and evaluation planning scores with the exception of the diagnosis of basal cell carcinoma.CONCLUSIONS: Primary care residents can diagnose and make evaluation plans for cancerous skin lesions, including malignant melanoma, at a level equivalent to that of dermatologists if they receive relevant, targeted education.

Psoriasis patients are enriched for genetic variants that protect against HIV-1 disease

An important paradigm in evolutionary genetics is that of a delicate balance between genetic variants that favorably boost host control of infection but which may unfavorably increase susceptibility to autoimmune disease. Here, we investigated whether patients with psoriasis, a common immune-mediated disease of the skin, are enriched for genetic variants that limit the ability of HIV-1 virus to replicate after infection. We analyzed the HLA class I and class II alleles of 1,727 Caucasian psoriasis cases and 3,581 controls and found that psoriasis patients are significantly more likely than controls to have gene variants that are protective against HIV-1 disease. This includes several HLA class I alleles associated with HIV-1 control; amino acid residues at HLA-B positions 67, 70, and 97 that mediate HIV-1 peptide binding; and the deletion polymorphism rs67384697 associated with high surface expression of HLA-C. We also found that the compound genotype KIR3DS1 plus HLA-B Bw4-80I, which respectively encode a natural killer cell activating receptor and its putative ligand, significantly increased psoriasis susceptibility. This compound genotype has also been associated with delay of progression to AIDS. Together, our results suggest that genetic variants that contribute to anti-viral immunity may predispose to the development of psoriasis.