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An 84-year-old woman was presented to an infectious disease clinic with hyperpigmented grey patches distributed symmetrically along her cheeks, chin and neck. The pigmentation had progressed in color over 7 months. For the preceding 4 years, the patient had been receiving suppressive oral minocycline therapy (100 mg twice daily) for a prosthetic knee infection. The patient's condition was diagnosed minocycline-induced skin hyperpigmentation. The minocycline was stopped, and therapy with doxycycline was initiated. The hyperpigmentation began to fade over the following 3 months. Minocycline is a tetracycline antibiotic. It has been used as a treatment for acne vulgaris and rosacea, although current Canadian guidelines do not recommend minocycline as a first-line drug for this indication. Hyperpigmentation of the skin, gingiva, teeth, bones, eyes, thyroid gland and other viscera has long been recognized as a potential side effect of long-term minocycline use, with an incidence of 3%-15%.

Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds. Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.

Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds. Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.

Community physicians may not encounter Charcot arthropathy frequently, and its symptoms and signs may be nonspecific. Patients often have a delay of several months before receiving a formal diagnosis and referral for specialty care. However, limited Canadian data are available. We evaluated the clinical history, treatment and outcomes of patients treated for Charcot arthropathy after prompt referral and diagnosis. We performed a retrospective chart review of 76 patients with diabetes (78 feet) who received nonoperative treatment for Charcot arthropathy in a specialty foot clinic between Jan. 20, 2009, and Mar. 26, 2018. Patients were referred to the foot clinic by community physicians for evaluation or were pre-existing patients at the foot clinic with new-onset Charcot arthropathy. Of the 78 feet included in our analyses, 52 feet (67%) were evaluated initially by a community physician and referred to the foot clinic, where they were seen within 3 ± 5 weeks. The remaining 26 feet (33%) were already being treated at the foot clinic. Most feet had swelling, erythema, warmth, a palpable pulse and loss of protective sensation. Ulcers were present initially in 23 feet (29%). Sixty-four feet (82%) with Charcot arthropathy were in Eichenholtz classification stage 1 and most had midfoot involvement. Nonoperative treatment included total contact casting (60 feet, 77%). Mean duration of nonoperative treatment until resolution for 55 feet (71%) was 6 ± 5 months. Surgery was performed on 20 feet (26%) for the treatment of infection and recurrent ulcer associated with deformity, including 6 (8%) lower limb amputations. Charcot arthropathy may resolve in most feet with early referral and nonoperative treatment, but remains a limb-threatening condition. Les médecins en milieu communautaire risquent peu de voir des cas d’arthropathie de Charcot, dont les signes et symptômes sont parfois non spécifiques. Souvent, les malades attendant des mois avant d’obtenir un diagnostic formel et d’être mis en contact avec des spécialistes. Toutefois, on dispose de peu de données canadiennes. Nous avons voulu explorer l’évolution clinique, le traitement et l’issue de la maladie chez les malades traités pour l’arthropathie de Charcot après une consultation et un diagnostics rapides. Nous avons procédé à une revue rétrospective des dossiers de 76 personnes diabétiques (78 pieds) ayant bénéficié d’un traitement non chirurgical pour l’arthropathie de Charcot dans une clinique du pied entre le 20 janvier 2009 et le 26 mars 2018. Ce sont les médecins en milieu communautaire qui avaient adressé leurs malades à la clinique du pied pour évaluation ou alors, il s’agissait de patients déjà suivis à la clinique du pied qui présentaient une arthropathie de Charcot de novo. Parmi les 78 pieds inclus dans nos analyses, 52 (67 %) ont d’abord été examinés par un médecin en milieu communautaire, puis ont fait l’objet d’une demande consultation à la clinique du pied, consultation qui a été réalisée en l’espace de 3 ± 5 semaines. Les 26 autres pieds (33 %) étaient déjà traités à la clinique du pied. La plupart des pieds présentaient enflure, érythème, chaleur, pouls palpable et perte de sensibilité protectrice. Des ulcères s’observaient initialement sur 23 pieds (29 %). Soixante-quatre pieds (82 %) touchés par l’arthropathie de Charcot se trouvaient au stade 1 de la classification d’Eichenholtz et la majorité présentaient une atteinte au milieu du pied. Le traitement non chirurgical reposait sur l’immobilisation et la décharge au moyen d’un plâtre à contact total (60 pieds, 77 %). La durée moyenne du traitement non chirurgical jusqu’à résolution pour 55 pieds (71 %) a été de 6 ± 5 mois. Vingt pieds (26 %) ont été opérés pour le traitement d’une infection et une récurrence d’ulcère associé à la difformité, incluant 6 amputations (8 %) au membre inférieur. L’arthropathie de Charcot peut rentrer dans l’ordre la plupart du temps moyennant une consultation et un traitement non chirurgical rapides, mais reste une maladie qui peut menacer la survie du membre affecté.

BACKGROUND: Pasteurella species are Gram‐negative coccobacilli that are a part of the normal oropharyngeal flora of numerous domestic animals. They have been recognized as a rare but significant cause of peritonitis in patients undergoing peritoneal dialysis (PD). A consensus about management strategies for PD‐associated peritonitis caused by Pasteurella species currently does not exist. METHODS: The microbiological database serving the Manitoba Renal Program was searched from 1997 to 2013 for cases of Pasteurella species PD‐associated peritonitis, and charts were reviewed. PubMed was searched for case reports and data were abstracted. RESULTS: Seven new local cases and 30 previously reported cases were analyzed. This infection is clinically similar to other forms of PD peritonitis, with household pet exposure appearing to be the strongest risk factor. Cats are the most commonly implicated pet. Direct contact between the pet and the equipment was commonly reported (25 of 37 patients) but was not necessary for infection to develop. The mean duration of treatment was 15 days. Complication rates were low, with only 11% of patients requiring PD catheter removal. There was no mortality reported. CONCLUSION: Pasteurella species are a rare cause of PD‐associated peritonitis that can be successfully treated with a two‐week course of intraperitoneal antibiotics with a high likelihood of catheter salvage.

Blastomyces dermatitidis is a dimorphic fungus endemic to Canada and the United States. Few reports regarding blastomycosis in Canada have been published. We retrospectively reviewed the medical charts of 143 patients with confirmed cases of blastomycosis diagnosed in hospitals in Manitoba, Canada, from 1988 through 1999. The annual incidence rate of blastomycosis in Manitoba was 0.62 cases per 100,000 population, compared with 7.11 cases per 100,000 population in the Kenora, Ontario district. The average age of patients was 38.0 years, and males accounted for 65.0% of cases. An increased incidence of blastomycosis was observed in the Aboriginal subpopulation. Organ systems involved were as follows: respiratory system (93.0% of cases), skin (21.0%), bone (13.3%), genitourinary tract (1.4%), and the central nervous system (1.4%); 6.3% of patients died, and death was associated with a short clinical course. This study provides a summary of the current status of blastomycosis in this area of endemicity in Canada.

Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds. Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.

Bacteria belonging to the Streptococcus anginosus group ( Streptococcus intermedius , Streptococcus constellatus and Streptococcus anginosus ) are capable of causing serious pyogenic infections, with a tendency for abscess formation. The present article reports a case of S anginosus group pyomyositis in a 47‐year‐old man. The pathogen was recovered from one of two blood cultures obtained from the patient, but speciation was initially not performed because the organism was considered to be a contaminant (viridans streptococci group). The diagnosis was ultimately confirmed using 16S ribosomal DNA sequencing of purulent fluid obtained from a muscle abscess aspirate. The present case serves to emphasize that finding even a single positive blood culture of an organism belonging to the S anginosus group should prompt careful evaluation of the patient for a pyogenic focus of infection. It also highlights the potential utility of 16S ribosomal DNA amplification and sequencing in direct pathogen detection from aspirated fluid in cases of pyomyositis in which antimicrobial therapy was initiated before specimen collection.

This new addition will provide an update on the current prophylaxis guidelines, the new diagnostic approach in the detection of the disease, the proposed schemas to predict prognosis, and the new treatment strategies to improve the outcome of patients afflicted with this serious condition. Endocarditis is a serious disease with ahigh rate of morbidity and mortality. The in-hospital mortality remains at 10-20%. The poor outcome ofpatients with this condition is due in large part to the delay in making thediagnosis which frequently can be elusive. As a result of its wide spectrum of manifestations, endocarditis canmimic many different conditions ranging from stroke to renal failure. In order to minimize the delay in diagnosis,clinicians need to always be mindful of the possibility that endocarditis maybe the cause of the symptoms. There have been ongoing efforts in thedevelopment of molecular probes and new imaging techniques to improve ourability to identify the disease early and reliably. New treatment strategies have been studiedwith the aim to prevent complications and to improve survival.Thestructure of the previous edition is preserved. The book is divided into three sections with the first section coveringthe historical perspective and basic principles, the second section dealingwith the diagnosis and management approaches and the last section on specificclinical situations that pose management dilemmas. All the chapters will be updated to include newinformation from the recent studies. Inparticular, the approach to the use of antibiotic prophylaxis will beextensively revised to present and discuss the implications of the currentguidelines from different national societies including the American HeartAssociation and the British Society for Antimicrobial Chemotherapy.This update is timely and should be ofinterest to all clinicians involved in the care of patients with this seriousdisease. This new edition will be a good resource forinternists, infectious disease specialists, cardiologists and cardiac surgeonsalike .