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Linezolid-Associated Serotonin Syndrome
A Report of Two Cases
Linezolid, a mild monoamine oxidase inhibitor, is a commonly used antibiotic drug for the treatment of complicated skin and skin structure infections, including diabetic foot infections. Use of linezolid has been associated with serotonin syndrome, a potentially life-threatening condition typically caused by the combination of two or more medications with serotonergic properties, due to increased serotonin release. The goals of this article are to highlight the risk factors associated with the development of serotonin syndrome related to the use of linezolid and to aid in its prevention and early diagnosis. In this case series we report on two hospitalized patients who, while being treated with linezolid for pedal infections, developed serotonin syndrome. Both individuals were also undergoing treatment with at least one serotonergic agent for depression and had received this medication within 2 weeks of starting the antibiotic drug therapy. In these individuals, we noted agitation, confusion, tremors, and tachycardia within a few days of initiation of linezolid therapy. Owing to the risk of serotonin toxicity, care should be taken when prescribing linezolid in conjunction with any other serotonergic agent. Although serotonin syndrome is an infrequent complication, it can be potentially life threatening. Therefore, risks and benefits of therapy should be weighed before use.
Background: Verrucae are caused by infection of epidermal keratinocytes by human papilloma virus (HPV). Although there are currently more than 100 known types of HPV, certain lesions are consistently caused by infection with one or a few types. Recent studies have identified the presence of unusual HPV types in anogenital and cervical condylomata (warts) of patients infected with human immunodeficiency virus (HIV). Although cutaneous verrucae are typically caused by HPV-1, HPV-2, and HPV-4, infection with HIV may predispose an individual to infection with an unusual HPV type.
Methods: We report the detection of a rare HPV type in a clinically aggressive plantar verruca from an HIV-positive patient. The viral DNA from this specimen was analyzed to identify the predominant HPV type. To complete this analysis, HPV DNA was extracted from the formalin-fixed specimen, followed by polymerase chain reaction with consensus HPV primers and digestion with a specific group of restriction endonucleases. The fragments were separated on an agarose gel, and the restriction fragment length polymorphism pattern was compared with known patterns for identification of the specific HPV type.
Results: Identification of HPV-69, an HPV type previously reported to be rare and associated with dysplastic lesions, was confirmed by HPV DNA dot-blot hybridization with specific DNA probes for each known HPV type.
Conclusions: Plantar verrucae in HIV-positive patients may be associated with unusual HPV types and should be analyzed and treated aggressively given the potential for a more distinct clinical manifestation. Additional lesional analysis studies are needed. (J Am Podiatr Med Assoc 99(1): 8–12, 2009)
Background:
Split-thickness skin grafts can be used for foot wound closure in diabetic and nondiabetic patients. It is unknown whether this procedure is reliable for all diabetic patients, with or without comorbidities of diabetes, including cardiovascular disease, neuropathy, retinopathy, and nephropathy.
Methods:
We retrospectively reviewed 203 patients who underwent this procedure to determine significant differences in healing time, postoperative infection, and need for revisional surgery and to create a predictive model to identify diabetic patients who are likely to have a successful outcome.
Results:
Overall, compared with nondiabetic patients, diabetic patients experienced a significantly higher risk of delayed healing time and postoperative complication/infection and, hence, are more likely to require revisional surgery after undergoing the initial split-thickness skin graft procedure. These differences seemed to be related more to the presence of comorbidities than to diabetic status itself. Diabetic patients with preexisting comorbidities experienced a significantly increased risk of delayed healing time and postoperative infection and a higher need for revisional surgery compared with nondiabetic patients or diabetic patients without comorbidities. However, there were no significant differences in outcome between diabetic patients without comorbidities and nondiabetic patients.
Conclusions:
For individuals with diabetes but without exclusionary comorbidities, split-thickness skin grafting may be considered an effective surgical alternative to other prolonged treatment options currently used in this patient population. (J Am Podiatr Med Assoc 103(3): 223–232, 2013)
Background: Along with significant case transmission, hospitalizations, and mortality experienced during the global severe acute respiratory syndrome coronavirus 2 pandemic, there existed a disruption in the delivery of health care across multiple specialties. We studied the effect of the pandemic on inpatients with diabetic foot problems in a Level I trauma center in central Ohio.
Methods: A retrospective chart review of patients necessitating a consultation by the foot and ankle surgery service were reviewed from the first 8 months of 2020. A total of 270 patients met the inclusion criteria and were divided into prepandemic (n = 120) and pandemic groups (n = 150). Data regarding demographics, medical history, severity of current infection, and medical or surgical management were collected and analyzed.
Results: The odds of undergoing any level of amputation was 10.8 times higher during the pandemic versus before the pandemic. The risk of major amputations (below-the-knee or higher) likewise increased, with an odds ratio of 12.5 among all patients in the foot and ankle service during the pandemic. Of the patients undergoing any amputation, the odds for undergoing a major amputation was 3.1 times higher than before the pandemic. In addition, the severity of infections increased during the pandemic, and a larger proportion of the cases were classified as emergent in the pandemic group compared to the prepandemic group.
Conclusions: The effect of the pandemic on the health-care system has had a deleterious effect on people with diabetes mellitus (DM)–related foot problems, resulting in more severe infections and more emergencies, and necessitating more amputations. When an amputation was performed, the likelihood that it was a major amputation also increased.
Background:
Onychomycosis and tinea pedis (athlete’s foot) are infections of the nails and skin caused by pathogenic fungi collectively known as dermatophytes. These infections are difficult to treat, and patients often relapse; it is thought that a patient’s footwear becomes infected with these fungal organisms and, thus, is an important reservoir for reinfection. Therefore, it is important to find an effective means for killing the dermatophytes that may have colonized the inner surface of the shoes of patients with superficial fungal infections. In this study, we developed an in vitro model for culturing dermatophytes in footwear and used this model to evaluate the effectiveness of a commercial ultraviolet shoe sanitizer in eradicating the fungal elements residing in shoes.
Methods:
Leather and athletic shoes (24 pairs) were inoculated with either Trichophyton rubrum or Trichophyton mentagrophytes (107 colony-forming units/mL) strains and were placed at 35°C for 4 to 5 days. Next, we compared the ability of swabbing versus scraping to collect microorganisms from infected shoes. Following the optimized method, shoes were infected and were irradiated with one to three cycles of radiation. The inner surfaces of the shoes were swabbed or scraped, and the specimens were cultured for dermatophyte colony-forming units.
Results:
Leather and canvas shoes were infected to the same extent. Moreover, scraping with a scalpel was overall more effective than was swabbing with a cotton-tipped applicator in recovering viable fungal elements. Irradiation of shoes with one, two, or three cycles resulted in reduction of fungal colonization to the same extent.
Conclusions:
The developed infected shoe model is useful for assessing the effectiveness of ultraviolet shoe sanitizers. Also, ultraviolet treatment of shoes with a commercial ultraviolet C sanitizing device was effective in reducing the fungal burden in shoes. These findings have implications regarding breaking foot infection cycles. (J Am Podiatr Med Assoc 102(4): 309–313, 2012)
Fluoroquinolones have been associated with tendinopathies. The authors present three cases of Achilles tendinopathy in which the patients’ symptoms were preceded by treatment for unrelated bacterial infections with ciprofloxacin. Although the exact mechanism of the relationship is not understood, those who engage in sports or exercise should be advised of the risk of quinolone-induced tendinopathy. (J Am Podiatr Med Assoc 93(4): 333-335, 2003)
Necrotizing fasciitis is a rare and potentially fatal infection, with mortality of up to 30%. This case report describes a patient recovering from a laryngectomy for laryngeal squamous cell cancer who developed nosocomial necrotizing fasciitis of the lower extremity due to Serratia marcescens. Only eight cases of necrotizing fasciitis exclusive to the lower extremity due to S marcescens have been previously reported. Patients with S marcescens necrotizing fasciitis of the lower extremity often have multiple comorbidities, are frequently immunosuppressed, and have a strikingly high mortality rate.
Onychomycosis is a common problem seen in clinical practice. Given the differential diagnosis of dystrophic nails, it is helpful to obtain a definitive diagnosis of dermatophyte infection before initiation of antifungal therapy. Potassium hydroxide preparation and fungal culture, which are typically used in the diagnosis of these infections, often yield false-negative results. Recent studies have suggested that nail plate biopsy with periodic acid–Schiff stain may be a very sensitive technique for the diagnosis of onychomycosis. In this article, we review the literature on the utility of histopathologic analysis in the evaluation of onychomycosis. Many of these studies indicate that biopsy with periodic acid–Schiff is the most sensitive method for diagnosing onychomycosis. We propose that histopathologic examination is indicated if the results of other methods are negative and clinical suspicion is high; therefore, it is a useful complementary technique in the diagnosis of onychomycosis. (J Am Podiatr Med Assoc 95(3): 258–263, 2005)
Necrotizing fasciitis is a devastating inflammatory infection requiring emergent medical treatment and surgical intervention. Even with timely management, the mortality rate of necrotizing fasciitis approaches 25%. The causative bacteria invade fascial planes and express toxins that advance rapidly. Here, we document a rare case of necrotizing fasciitis from Serratia marcescens infection. Serratia marcescens is capable of inducing a necrotizing inflammatory cascade mediated by extracellular cytotoxin and lipase. In this case report, a 90-year-old man presented to our emergency department from a long-term care facility with a relatively benign-appearing ulcer with surrounding cellulitis on the right ankle. Blood cultures and wound cultures confirmed the organism to be S marcescens. A multidisciplinary team was consulted for management. The patient received antibiotic therapy and medical support, but because of his comorbid conditions and social situation, the designated medical decision maker opted for comfort care rather than aggressive surgical debridement. The patient progressed through the clinical stages of necrotizing fasciitis. Within 36 hours, the patient died as result of sepsis-induced organ failure.
Background
Retrograde intramedullary nailing for tibiotalocalcaneal arthrodesis (TTCA) is used for severe hindfoot deformities, end-stage arthritis, and limb salvage. The procedure is technically demanding, with complications such as infection, hardware failure, nonunion, osteomyelitis, and possible limb loss or death. This study reports the outcomes and complications of patients undergoing TTCA with a femoral nail, which is widely available and offers an extensive range of lengths and diameters.
Methods
We performed a retrospective review of 104 patients who underwent 109 TTCAs using a femoral nail as the primary procedure (January 2006 through December 2016). Demographic data, risk factors, and outcomes were evaluated.
Results
At final follow-up, the overall clinical union rate was 89 of 109 (81.7%). Diabetes mellitus was negatively associated with limb salvage (P = .03), and peripheral neuropathy (P = .02) and Charcot's neuroarthropathy (P = .03) were negatively associated with clinical union. Only four patients (3.8%) underwent proximal amputation, at an average of 6.1 months, and 11 patients (10.6%) died, at a mean of 38.0 months. The most common complication was ulceration in 27 of 109 limbs (24.8%), followed by infection in 25 (22.9%). Twenty-three patients (22.1%) underwent revision procedures, at a mean of 9.4 months. Thirteen of these 23 patients (56.5%) had antibiotic cement rod spacers/rods for deep infection–related complications.
Conclusions
Use of a femoral nail has been shown to provide similar outcomes and limb salvage rates compared with other methods of TTCA reported for similar indications in the literature.
