No abstract

No abstract

No abstract

A 76‐year‐old man receiving long‐term prednisone therapy for rheumatoid arthritis had a four‐part intertrochanteric fracture after a fall. The patient underwent an open reduction with internal fixation and dynamic hip screw placement. Two months later, when the patient presented with significant pain and difficulty ambulating, radiographs revealed dissociation of the compression screw from the femoral head. At the time of removal of failed hardware, a total hip replacement procedure was aborted when intraoperative findings were consistent with infection. Thorough irrigation and debridement were performed, with placement of antibiotic‐impregnated cement spacers. One month after a 4‐week course of intravenous cefazolin, the patient underwent left total hip arthroplasty. Intraoperative cultures grew methicillin‐resistant Staphylococcus aureus and Corynebacterium jeikeium. A 4‐week course of intravenous vancomycin was followed by long‐term antibiotic suppression with long‐term minocycline (100 mg twice daily). Six months after starting minocycline, the patient noticed a blue‐gray discoloration of the forearms. During the next 4 months, the pigmentation progressed considerably. He was admitted to Mayo Clinic for a myocardial infarction. Three‐vessel coronary artery disease was discovered, necessitating bypass grafting. Before surgery, dermatology was consulted. A main concern of the primary service was the discoloration representing ecchymoses in a surgical candidate with a possible bleeding diathesis. Cutaneous examination revealed slate gray, ill‐defined patches in the preauricular, flank, upper thigh, and shoulder areas. Similar patches coalesced on the upper and lower extremities (Fig. 1). There was no scleral or mucous membrane involvement. Histologically, minocycline pigmentation with pigment‐laden macrophages and free dermal pigment in the papillary and superficial reticular dermis stained positive with Prussian blue and Fontana‐Masson (Fig. 2). Minocycline was discontinued, and the patient was started on trimethoprim‐sulfamethoxazole double strength once daily for long‐term antimicrobial therapy. 1 Minocycline‐induced slate gray discoloration of the (a) arms and (b) shins 2 Pigment‐laden macrophages and free dermal pigment. (Hematoxylin‐eosin; original magnification ×600)

A 26-year-old woman presented with a high-grade fever and chills of 2 days' duration. She complained of associated joint pain, especially in the wrists and knees. One day before admission, tender skin lesions began to develop on the fingers, and subsequently spread to the more proximal extremities. The patient recalled having a sore throat and a nonproductive cough before the onset of the fever and eruption. The past medical history was significant for Gardnerella vaginitis and several urinary tract infections. The patient was taking oral contraceptive pills; her most recent menstruation was 3 weeks before admission. She reported having sexual intercourse with her boyfriend 2 weeks before admission. The patient's temperature was 40 degrees C. Dermatologic examination revealed a 6-mm, hemorrhagic pustule on an ill-defined pink base, overlying the volar aspect of the left second proximal interphalangeal joint (Fig. 1a). Scattered on the upper and lower extremities were occasional round, ill-defined pink macules with central pinpoint vesiculation (Fig. 1b). A skin biopsy of the digit revealed a dense neutrophilic infiltrate with leukocytoclasis and marked fibrin deposition in the superficial and deep dermal vessels (Fig. 2a). Gram stains demonstrated the presence of Gram-negative diplococci (Fig. 2b). Laboratory findings included leukocytosis (leukocyte count of 20 x 109/L, with 81% neutrophils). Analysis of an endocervical specimen by polymerase chain reaction was positive for Neisseria gonorrhoeae and negative for Chlamydia trachomatis. Throat and blood cultures grew N. gonorrhoeae. Specimen cultures obtained by skin biopsy yielded no growth. Results of serologic analysis for human immunodeficiency virus, hepatitis, syphilis, and pregnancy were negative. Beginning on admission, intravenous ceftriaxone, 2 g, was administered every 24 h for 6 days, followed by oral cefixime, 400 mg twice daily for 4 days. Oral azithromycin, 1 g, was administered to treat possible coinfection with C. trachomatis. By treatment day 4, the patient was afebrile, with the resolution of leukocytosis and symptomatic improvement of arthralgias.