A 40-year-old woman presented to the Brooke Army Medical Center Emergency Department complaining of 2 episodes of gross hematuria. Computed tomography and intravenous pyelogram revealed a right renal mass. A radical nephrectomy was performed with complete excision of the mass with negative margins on histological examination. The patient was diagnosed with renal medullary carcinoma, Fuhrman grade 4, based upon histological examination. A positron emission tomography scan revealed no other evidence of the disease. The pathologic stage was stage I renal medullary carcinoma. Four months after her nephrectomy, the patient developed a papule on her right frontal scalp. Initially thought to be a cyst, the papule increased in size over the course of 2 months and eventually ulcerated. At that time, she presented to the Wilford Hall Medical Center Dermatology Clinic with a 2.5-cm ulcerated tumor with pink rolled borders. A punch biopsy of the tumor revealed an infiltrating carcinoma with scattered glandular lumina and desmoplastic and mucinous stroma. The carcinoma was completely intradermal. Expert consultation confirmed the diagnosis of metastatic renal medullary carcinoma. Clear cell (conventional) and papillary renal cell carcinomas are known to metastasize to the skin, including the scalp. Renal medullary carcinoma commonly metastasizes to the regional lymph nodes, lung, liver, or adrenals. To our knowledge, this is the first report of a cutaneous metastasis of renal medullary carcinoma.

DESIGN: Reusable tourniquets (n=200) were collected after being used for one day in the outpatient blood collection center (n=100) or during morning blood collection rounds on inpatient wards (n=100). Tourniquets were cultured and growth was screened for A. baumannii and S. aureus. A. baumannii isolates were identified using colonial morphology, oxidase, and GNI+ card on Vitek Legacy. S. aureus isolates were identified and screened for MRSA using colonial morphology, catalase, Staphaurex, and Oxacillin screening agar. RESULTS: Each outpatient tourniquet was used on an average of 33 patients and each inpatient tourniquet was used on an average of 11 patients. The overall contamination rate was 9% (18/200). A. baumannii was isolated from 11% (11/100) of the outpatient tourniquets and 3% (3/100) of the inpatient tourniquets. Methicillin-susceptible S. aureus was isolated from 2% (2/100) of the outpatient tourniquets and 3% (3/100) of the inpatient tourniquets. No MRSA was isolated. One outpatient tourniquet had both A. baumannii and methicillin-susceptible S. aureus. CONCLUSIONS: Reusable tourniquets could serve as a potential reservoir for bacterial pathogens.

Lymphocutaneous sporotrichosis is a mycotic disease caused by traumatic inoculation of the dimorphic fungus Sporothrix schenckii, found ubiquitously in decaying vegetation. The potential for outbreaks, difficulty with timely diagnosis, as well as the prolonged treatment course and recovery from surgical intervention can have a substantial impact on the medical readiness of service members. Treatment with the antifungal therapy of choice, itraconazole, requires close patient monitoring for the duration of treatment for clinical response, drug tolerance, as well as therapeutic drug levels. We present a case of a U.S. Army enlistee with sporotrichosis contracted during basic training, highlighting the impact of delayed diagnosis and prolonged treatment course and recovery on medical readiness.

Patients with toxic epidermal necrolysis, a condition that causes full thickness epidermal necrosis that affects over 30% of the skin surface and mucosal membranes, often develop comorbid infections throughout the recovery of the disease [1]. While most commonly these are related to a bacterial source, infections due to viral, mycobacterial, and rarely fungal organisms occur. We present a case of a patient who developed a deep cutaneous fungal infection caused by Trichosporon asahii and discuss the management.