Hepatitis D virus (HDV) infection is highly prevalent in patients with chronic hepatitis B (CHB). AASLD guidelines recommend a risk-based screening approach. Our aim was to ascertain if the risk-based approach leads to appropriate HDV screening, identify targets to improve screening rates, and study HDV clinical burden. CHB patients screened for HDV from 01/2016 to 12/2021 were identified. Level of training and specialty of providers ordering HDV screening tests were determined. HDV seropositive (HDV+) patient charts were reviewed for the presence of individual risk factors per the AASLD guidelines to determine if they met screening criteria. The severity of liver disease at the time of HDV screening was compared between the HDV+ group and a matched (based on age, hepatitis B e antigen status, BMI and sex) HDV seronegative (HDV−) group. During the study period, 1444/11,190 CHB patients were screened for HDV. Most screening tests were ordered by gastroenterology (90.2%) specialists and attending physicians (80.5%). HDV+ rate was 88/1444 (6%), and 72 HDV+ patients had complete information for analysis. 18% of HDV+ patients would be missed by a risk-based screening approach due to unreported or negative risk factors (see Table ). A significantly higher number of HDV+ patients had developed significant fibrosis (p = 0.001) and cirrhosis (p < 0.01) by the time of screening than HDV− (n = 67) patients. In conclusion, targeted interventions are needed towards trainees and primary care clinics to improve screening rates. Current risk-based criteria do not appropriately screen for HDV. It is time for universal screening of HDV in CHB patients.

INTRODUCTION: Ecthyma gangrenosum (EG) is a necrotizing vasculitis, commonly observed in immunocompromised patients with Pseudomonas aeruginosa bacteremia. Rarely, it can be seen with other bacterial, fungal, and viral infections. We report a rare etiology of EG in an immunocompetent patient caused by methicillin-sensitive Staphylococcus aureus (MSSA). CASE PRESENTATION:A 62-year-old man with hypertension presented to the emergency department for pain and swelling of the right lower extremity after a crush injury one week prior. Initial vital signs were remarkable for a blood pressure of 84/43 mmHg and a pulse rate of 134 beats per minute. Examination revealed a gangrenous right great toe and well-circumscribed purpuric papules with a violaceous border and central pallor on the patient's skin most prominent over the legs and lower abdomen. Laboratory findings were significant for leukocytosis and lactic acidosis. Intravenous fluids were initiated, blood cultures were collected, and he was started on vancomycin and cefepime. He rapidly progressed to septic shock requiring vasopressors and was admitted to the intensive care unit. The patient underwent amputation of the right great and punch biopsies of the skin lesions. Despite aggressive critical care management, he continued to deteriorate and developed acute hypoxemic respiratory failure and acute kidney injury requiring renal replacement therapy. Blood, wound, and urine cultures grew MSSA. Skin biopsy results revealed necrobiosis and suppurative dermatitis with gram-positive cocci in clusters, consistent with EG due to MSSA bacteremia. Antibiotic coverage was narrowed to nafcillin, however, he continued to deteriorate with progressive multiorgan failure. He was ultimately transitioned to comfort measures and died peacefully in the presence of family.DISCUSSION: To the best of our knowledge, there are only two reported cases of EG secondary to MSSA infection (1,2). One of a healthy 15-month-old girl who developed EG, and toxin-mediated systemic findings and the second of a 54-year-old female with metastatic gastric adenocarcinoma and recent chemotherapy. This is the first reported case of an immunocompetent adult patient with MSSA EG. Reported predisposing risk factors for EG include immunodeficiency, recent chemotherapy, burns, malnutrition, and tuberculosis infection. The literature describes two different forms of EG, bacteremic and non-bacteremic. Mortality rates in patients with EG due to bacteremia are significantly higher compared to patients without bacteremia (3).CONCLUSIONS: This case is unique as our patient had a rare presentation of EG due to MSSA bacteremia with none of the previously described predisposing risk factors.

Background: Ecthyma gangrenosum (EG) is a necrotizing vasculitis most observed in immunocompromised patients with Pseudomonas aeruginosa bacteremia. Rarely, it can be seen with other bacterial, fungal, and viral infections [1]. We report a rare etiology of EG in an immunocompetent patient caused by methicillin-sensitive Staphylococcus aureus (MSSA).Case Report: A 62-year-old man with hypertension and hyperlipidemia presented to the emergency department for pain, swelling, and blackish discoloration of the right lower extremity. He suffered a crush injury to the right great toe one week prior. Initial vital signs were remarkable for hypotension with a blood pressure of 84/43 mmHg and a pulse rate of 134 beats per minute. On evaluation, the patient appeared acutely ill. Examination of his right lower extremity revealed a gangrenous right great toe (Figure 1). Further examination of the skin revealed scattered, well-circumscribed purpuric papules with a violaceous border and central pallor most prominent on the patient's legs and lower abdomen (Figure 2). Laboratory findings were significant for leukocytosis, thrombocytopenia, and lactic acidosis. The patient was administered intravenous fluids for hypotension. Blood cultures were collected and the patient was started on broad-spectrum antibiotics DISHANT JOY SHAH RANDY LEIBOWITZ

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