A 25‐year‐old woman presented in October 1999 with fever, nausea, vomiting, and a nodular eruption that had developed over the previous 7 days. Her past medical history was significant for chronic sclerosing cholangitis, which necessitated a liver transplantation in 1994 and a second one in 1998 due to graft rejection. Upon admission, she was taking the following medications: prednisone 20 mg q.d., cyclosporine 375 mg p.o. b.i.d., sirolimus 10 mg p.o. q.d., levofloxacin 500 mg p.o. q.d., and ganciclovir 1000 mg p.o. t.i.d. On skin examination, there were tender, nonfluctuant, erythematous, subcutaneous nodules, 0.3–1.0 cm in diameter, scattered on her arms and legs (see Fig. 1). While undergoing diagnostic evaluation, the patient was empirically treated with intravenous antimicrobials for presumed sepsis as well as increased dosages of glucocorticosteroids for the possibility of acute graft rejection. Her laboratory data were significant for elevated liver function tests, blood urea nitrogen, and creatinine. A punch biopsy of a nodule on her left forearm showed a neutrophilic and histiocytic lobular and septal panniculitis (see Fig. 2), and all special stains, including acid‐fast bacillus (AFB) stains, and tissue cultures were negative for infectious organisms. 1 Erythema nodosum‐like nodules on the leg 2 Septal and lobular panniculitis in a skin nodule from the arm (× 75) Although the patient's eruption was compatible with erythema nodosum both clinically and histologically, it failed to improve during the next few weeks with an increased dosage of glucocorticosteroids. A second skin biopsy was then performed on a lower extremity nodule and it revealed a necrotizing panniculitis with numerous AFB. Within 7 days, skin tissue culture grew Mycobacterium chelonae/abscessus complex sensitive to amikacin and clarithromycin, but resistant to cefoxitin, doxycycline, ciprofloxacin, sulfamethoxasole/trimethoprim, and erythromycin. Re‐examination of the initial biopsy revealed a very small focus of AFB which was not previously recognized. Due to persistently elevated liver function tests, the patient underwent a liver biopsy which was negative for AFB on histopathologic examination. A tissue culture from the liver, however, grew M. chelonae/abscessus complex which had the same sensitivity and resistance profile as the organism isolated from the skin. A bone marrow biopsy and culture, as well as repeated blood cultures, were all negative for AFB. The patient was initially started on 2.25 g of piperacillin/tazobactam every 6 h for the first day and then switched to clarithomycin 500 mg p.o. b.i.d. and continued on levofloxacin 500 mg p.o. q.d. The skin nodules rapidly decreased in size within several days; however, new lesions appeared on the upper and lower extremities during the next month. The eruption regressed significantly with the addition of intravenous amikacin 800 mg q.d. to the antimicrobial regimen, but again new nodules and intermittent fevers reappeared over the course of the next month. During the next 2...

A 15-year-old boy with a history significant for multiple respiratory infections since birth presented for evaluation of acne vulgaris. He was initially prescribed doxycycline, topical tretinoin, and topical clindamycin solution, with the later addition of a benzoyl peroxide preparation to his regimen. The patient returned 6 months later after having been diagnosed with CF (cystic fibrosis) by sweat testing and genetic testing. His skin condition had not responded adequately to prior therapy, so all acne medications were discontinued. The 84-kg patient was started on 80 mg (0.95 mg/kg/d) of isotretinoin (13-cis-retinoic acid) daily. The patient's dose was decreased to 40 mg/d 2 weeks later following an episode of blood in his stool and epistaxis. At the 1- and 2-month follow-up visits, the patient reported improvement in his acne and mentioned that his lung secretions seemed reduced. His acne cleared after 4 months of therapy, so the isotretinoin was discontinued. The patient and his mother noted that no respiratory infections had occurred during the course of therapy. The patient's acne relapsed nearly 2 years later, so isotretinoin was restarted at 60 mg/d. During the next 7 months while on the drug, he experienced no further episodes of epistaxis or bloody stools and his acne had resolved by the end of therapy. The patient and his mother again reported fewer bronchopulmonary secretions and no infections requiring antibiotics during treatment with isotretinoin. This was unusual because he had experienced numerous respiratory infections requiring antibiotics during the prior 2 years. Since discontinuing the drug, the patient has had intermittent pulmonary infections and exacerbations in the symptomatology of his CF.

AimYouth ages 12–24 account for approximately 20% of overdoses and yet are poorly reached by opioid agonist treatment (OAT), the most widely recommended treatment for opioid use disorder (OUD). This study contributes to understanding this critical gap by describing youths' patterns of OAT engagement at a novel integrated youth‐specific OAT program.MethodsA retrospective chart review was carried out on electronic medical records of n = 23 youth with OUD accessing a community‐based integrated youth services (IYS) centre. Data abstraction focused on four domains: sociodemographic, social determinants of health, patterns of OAT engagement, and other services utilized.ResultsYouths' mean age was 22.6 years (SD = 2.1), with a mean age of first opioid use of 17.4 (SD = 2.7). Youth reported extensive histories of adverse childhood experiences, concurrent mental and physical health complications, and poly‐substance use. All youth were offered OAT and 83% initiated treatment with buprenorphine/naloxone, methadone, or slow‐release oral morphine. Among those initiating OAT, 42.1% were considered stable on OAT.ConclusionsTo our knowledge, this is the first empirical study to describe youths' OAT engagement in an integrated youth‐specific OAT program. Our findings demonstrated that a high proportion of youth with OUD initiated OAT in this novel program with varying degrees of OAT stability. These findings can be used to inform the development and implementation of youth‐specific and integrated OAT. To account for the novelty of this area of study and small sample sizes, future collaborative efforts across IYS initiatives should be considered, including mixed method approaches to understand outcomes and experiences.

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