A 66-year-old man with diabetes and cirrhosis due to chronic hepatitis C infection (HCV RNA >1,000,000 IU/mL) developed a creatinine rise from 0.5 mg /deciliter to 2.6 mg/deciliter. The patient's fingernails demonstrated significant changes compared to a normal fingernail, with a white band (lunula) occupying more than 50 % of the nail bed proximally, suggestive of Lindsay's nail. (Figs. 1 and 2) Renal biopsy demonstrated membranoproliferative glomerulopathy and he was started on hemodialysis.A clinical differentiation between Lindsay's nail (half-andhalf nail) and Terry's nail is difficult. In Lindsay's nail, the proximal part of the nail is white, while the distal portion occupying 20 % to 60 % of nail bed is reddish-brown and does not fade with pressure. 1,2 The cause of Lindsay's nail is unclear, but the distal reddish-brown band might be the result of an increased concentration of β-melanocyte-stimulating hormone. 2 This condition can be found in up to 40 % of patients of chronic kidney disease. 1 On the other hand, Terry's nail is defined as a 0.5-3.0 mm brown to pink distal band with proximal nail bed whiteness occupying approximately 80 % of nail bed. 3 This condition is frequently associated with cirrhosis, chronic congestive heart failure, and adult-onset diabetes mellitus. 3

A n 87-year-old woman with COPD presented with sudden-onset shortness of breath. She was tachypneic, with increased work of breathing and decreased breath sounds over her right hemithorax. She was intubated and had a right chest tube placed for acute respiratory failure and tension pneumothorax. Shortly afterward, she developed massive subcutaneous emphysema involving her arms, breasts, abdomen and right thigh. Chest radiography was performed after the procedures. Two days later, computed tomography imaging of the chest was performed. A chest drainage system showed persistent air leak without resolving subcutaneous emphysema. The patient subsequently underwent a right thoracotomy with right lower lung wedge resection. The subcutaneous emphysema improved significantly.Common causes of subcutaneous emphysema include blunt trauma, pneumothorax, pertussis, rib fracture, ruptured bronchial tube or esophagus, or a complication of tube thoracotomy. Clinical findings include swelling and crepitus over the involved site. In general, subcutaneous emphysema is self-limited, but respiratory and circulatory difficulties can occur due to compression of the trachea and great vessels at the thoracic inlet. 1 Successful treatment techniques for massive subcutaneous emphysema have been reported. 2 Bilateral infraclavicular incisions and subcutaneous drain by trocar-type chest tube have been successfully performed in a small number of cases. 2-4 These techniques were considered effective and safe.

Objective: To estimate the incidence of IFD in multiple myeloma patients receiving autologous stem cell transplantation (ASCT) using novel agents (bortezomib, thalidomide) in addition to high-dose melphalan (VTD Mel). Patients and methods: Retrospective chart review of patients who received an ASCT with the novel regimen VDT Mel between 2012 and 2014 at UIHC. All toxicities related to transplant regimen were calculated for the first 100 days after ASCT. IFD were classified as proven, probable and possible according to the EORTC/MSG revised classification, 2008. Results: 100 consecutive patients who received ASCT with VTD Mel conditioning were analyzed; 47 patients received a single and 53 had tandem transplants (TT), respectively; all patients received standard fluconazole prophylaxis of 100 mg per day. Only infections ≥ grade 3 were listed; there were a total 5 episodes of IFD with 4 proven and 1 probable fungal infections. Only 1 of the 4 proven infections was a mold infection (Alternaria sp).The 3 other proven infections were candida sepsis; 2 occurred in the same patient with the TT. Infections occurred between 6 and 10 days post-transplant. All patients were treated with appropriate antifungal therapy and one patient with proven mold infection required debridement of the sinus. There were no mortalities related to fungal infections in the first 100 days or long term with a median follow-up of 16.2 months. All patients except one had extensive prior therapy with 3 lines. We observed false positive beta D glucan and galactomannan tests in 7 other patients. Conclusion: This is the first study to report on the rates of invasive fungal disease in MM patients treated with novel agents as part of conditioning regimen. The rate of IFD, 4% (4/100 patients) in our patients, is within the range of published literature which reported IFD rates of~2.5% and~15% in patients receiving ASCT and more than 3 lines of therapy, respectively. We did not observe any mortality associated with IFD. History of prior heavy chemotherapy could be an additional risk factor. Risk of infection is high in the early posttransplant phase and prompt, aggressive treatment may lead to good outcomes. Fluconazole remains the standard prophylactic agent, since the duration of neutropenia is limited for most patients.

A 28-year-old woman presented with two days of painful pustules on her chest and back. She also had fever and chills but denied cough or dyspnea. On examination, the temperature was 38.6°C, blood pressure was 93/51 mm Hg, and pulse was 130 beats per minute. Examination of her back ( Fig. 1) and ear ( Fig. 2) revealed erythematous plaques mixed with scattered pustules. IV fluid and vancomycin were given for possible septic shock. Punch biopsy of the skin was compatible with a clinical diagnosis of generalized pustular psoriasis (GPP). GPP is a rare subtype of psoriasis. It is characterized by acute, generalized pustules on erythematous or scaly skin.1 It is considered the most severe type of psoriasis. The pustules are aseptic; therefore, therapeutic or prophylactic antimicrobial therapies are not indicated.1 This subtype of psoriasis can be fatal and requires immediate medical care. The differential diagnosis includes acute generalized exanthematous pustulosis, subcorneal pustular dermatosis and IgA pemphigus, which can present with pustular lesions. Rehydration and supportive skin care are usually indicated for most cases. The National Psoriasis Foundation has recommended using acitretin, cyclosporine, or methotrexate as first-line therapy.2 Systemic steroids should be avoided in the treatment of psoriasis because of the risk of worsening psoriasis.Acknowledgements: