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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Case 1&#46; &#40;A&#41; Psoriatic erythroderma&#46; &#40;B&#41; CT scan shows an abscess in the iliac muscle&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The risk of developing bacteremia and sepsis in patients with erythroderma has not been extensively studied&#46; The most frequent foci of bacteremia in adults and elderly patients are the urinary&#44; biliary&#44; and respiratory&#46; The cutaneous origin should be considered in the case of extensive cutaneous disease&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In elderly and immunosuppressed patients&#44; bacteremia can go unnoticed until it causes the involvement of some other organs or tissues&#46; Soft tissue infection&#44; such as an abscess in the hip musculature&#44; is a possible complication&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Psoas abscess is an uncommon but life-threatening condition&#44; especially due to frequent delays in diagnosis&#46; Symptoms are not specific&#58; Hip&#44; back&#44; thigh&#44; or abdominal pain and&#44; occasionally&#44; fever&#46; Early diagnosis and treatment are key to preventing complications such as septic shock and death&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Psoas abscess can be classified as primary when it is due to hematogenous or lymphatic spread&#44; or secondary when it is caused by contiguous infection&#46; Primary abscesses are more frequent in children&#44; developing countries&#44; and immunocompromised patients&#46; Risk factors include trauma&#44; osteoarthritis&#44; diabetes&#44; HIV infection&#44; intravenous drug user&#44; renal failure&#44; and immunosuppressives&#46; <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;SA&#41; is the most common agent in primary abscesses &#40;42&#46;9&#37;&#41;&#44; followed by <span class="elsevierStyleItalic">Streptococcus viridans</span> &#40;19&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">We report the case of two patients with erythroderma and hip abscess&#46; Patient 1 was a 70-year-old woman who presented persistent psoriatic erythroderma despite treatment with etretinate&#44; methotrexate&#44; and cyclosporine &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; She was admitted to the hospital in March 2021 with a Psoriasis Area and Severity Index &#40;PASI&#41; of 41&#44; and a body surface area &#40;BSA&#41; of 58&#46; The psoriatic plaques were highly inflammatory with broken pustules on their surface&#44; but without clear foci of erosions&#46; One month later&#44; she reported left thigh pain&#46; No abnormalities were detected by X-ray and ultrasonography&#46; Within one week&#44; she developed chills and a fever&#46; Blood cultures were positive for methicillin-sensitive SA &#40;MSSA&#41;&#46; With the suspicion of an infectious complication in the hip&#44; MRI was requested&#44; revealing a pus collection into the iliac muscle&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Patient 2 was a 76-year-old man who had a 2-year history of eczema outbreaks&#46; He was admitted to the hospital after developing erythroderma with lymphadenopathy &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; A skin biopsy confirmed the clinical suspicion of mycosis fungoides&#46; The complementary tests did not show clonality in peripheral blood or lymph nodes&#44; so the diagnosis of mycosis fungoides stage IIIa &#40;T4N1aM0B0&#41; was established&#46; Over the following days&#44; the patient developed malaise&#44; fever&#44; and hip pain&#46; Blood cultures were positive for <span class="elsevierStyleItalic">MSSA</span> and <span class="elsevierStyleItalic">Streptococcus pyogenes</span>&#46; Body CT showed an iliac abscess&#46; Endocarditis was discarded as the patient had a mechanical heart valve &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">There is little written in the literature about the risk of bacteremia and infectious complications in patients with extensive chronic dermatoses&#46; A large Indian retrospective study evaluated the etiology and frequency of sepsis in patients admitted to the dermatology unit<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a>&#46; Among 860 patients&#44; 4&#46;65&#37; developed sepsis&#46; Within these cases&#44; vesiculobullous diseases were the most frequent diagnosis &#40;42&#46;5&#37;&#41;&#44; followed by erythroderma &#40;25&#37;&#41;&#46; <span class="elsevierStyleItalic">Methicillin-resistant SA &#40;MRSA&#41;</span> was the most common organism&#44; but also <span class="elsevierStyleItalic">MSSA</span> was isolated in 8&#46;7&#37; of the patients&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Erythroderma may be a portal of entry to bacteremia as it involves an epidermal barrier dysfunction&#46; Also&#44; high-dose steroids and immunosuppressives are typically used in these patients&#44; which favor infections and might cover up symptoms&#46; Routier et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> describe 2 patients with psoas abscesses caused by streptococcal infection with a cutaneous portal of entry&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">On the other hand&#44; psoriatic erythroderma may be triggered by infections&#46; Green et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> report 5 patients with erythrodermic psoriasis and hidden SA bacteremia&#46; Skin manifestations only got better when the infection was controlled&#46; Although it is unusual&#44; bacteremia might have come from a primary abscess exacerbating skin lesions secondarily&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">SA colonization has been associated with increased BSA involvement in psoriasis<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> and cutaneous T-cell lymphoma &#40;CTCL&#41;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a>&#46; CTCL patients frequently present bacterial infections&#44; particularly SA&#46; Staphylococcal decolonization often results in clinically significant improvements<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The reason why abscesses in the iliopsoas are formed is not clear&#46; A lower limb or perineal wound could explain the predisposition for an abscess to appear in that area&#46; It is also a well-vascularized region where microorganisms could seed&#46; In addition&#44; elderly patients may suffer from osteoarthritis or trauma&#44; which predisposes them to infection&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The diagnosis is based on clinical symptoms and imaging tests&#46; CT and MRI are the gold standards&#44; but in the early stages&#44; they can present false negatives<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a>&#46; That is why it is important to have this diagnosis in mind and repeat imaging tests if necessary&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Treatment consists of broad-spectrum antibiotics and abscess drainage&#46; Surgical drainage is the traditional treatment&#44; but image-guided percutaneous drainage is an effective alternative&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In short&#44; erythroderma involves an epidermal barrier dysfunction that predisposes to infection and bacteremia&#46; Primary psoas abscess probably occurs as a consequence of hematogenous seeding&#46; Therefore&#44; erythroderma should be considered a risk factor&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">A high degree of suspicion is needed for an early diagnosis&#58; Thigh&#44; hip&#44; or back pain and bacteremia in an erythrodermic patient are mandatory to discard an iliopsoas abscess&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest</p></span></span>"
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Case and Research Letter
A Life-Threatening Infection in Patients With Erythroderma: Psoas Abscess
Una infección potencialmente mortal en pacientes con eritrodermia: absceso de psoas
A. Taibo
Corresponding author
ana.taibo.martinez@sergas.es

Corresponding author.
, N. Martínez Campayo, S. Paradela, E. Fonseca
Department of Dermatology, University Hospital of A Coruña, Spain
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        "titulo" => "Una infecci&#243;n potencialmente mortal en pacientes con eritrodermia&#58; absceso de psoas"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Case 1&#46; &#40;A&#41; Psoriatic erythroderma&#46; &#40;B&#41; CT scan shows an abscess in the iliac muscle&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The risk of developing bacteremia and sepsis in patients with erythroderma has not been extensively studied&#46; The most frequent foci of bacteremia in adults and elderly patients are the urinary&#44; biliary&#44; and respiratory&#46; The cutaneous origin should be considered in the case of extensive cutaneous disease&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In elderly and immunosuppressed patients&#44; bacteremia can go unnoticed until it causes the involvement of some other organs or tissues&#46; Soft tissue infection&#44; such as an abscess in the hip musculature&#44; is a possible complication&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Psoas abscess is an uncommon but life-threatening condition&#44; especially due to frequent delays in diagnosis&#46; Symptoms are not specific&#58; Hip&#44; back&#44; thigh&#44; or abdominal pain and&#44; occasionally&#44; fever&#46; Early diagnosis and treatment are key to preventing complications such as septic shock and death&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Psoas abscess can be classified as primary when it is due to hematogenous or lymphatic spread&#44; or secondary when it is caused by contiguous infection&#46; Primary abscesses are more frequent in children&#44; developing countries&#44; and immunocompromised patients&#46; Risk factors include trauma&#44; osteoarthritis&#44; diabetes&#44; HIV infection&#44; intravenous drug user&#44; renal failure&#44; and immunosuppressives&#46; <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;SA&#41; is the most common agent in primary abscesses &#40;42&#46;9&#37;&#41;&#44; followed by <span class="elsevierStyleItalic">Streptococcus viridans</span> &#40;19&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">We report the case of two patients with erythroderma and hip abscess&#46; Patient 1 was a 70-year-old woman who presented persistent psoriatic erythroderma despite treatment with etretinate&#44; methotrexate&#44; and cyclosporine &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; She was admitted to the hospital in March 2021 with a Psoriasis Area and Severity Index &#40;PASI&#41; of 41&#44; and a body surface area &#40;BSA&#41; of 58&#46; The psoriatic plaques were highly inflammatory with broken pustules on their surface&#44; but without clear foci of erosions&#46; One month later&#44; she reported left thigh pain&#46; No abnormalities were detected by X-ray and ultrasonography&#46; Within one week&#44; she developed chills and a fever&#46; Blood cultures were positive for methicillin-sensitive SA &#40;MSSA&#41;&#46; With the suspicion of an infectious complication in the hip&#44; MRI was requested&#44; revealing a pus collection into the iliac muscle&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Patient 2 was a 76-year-old man who had a 2-year history of eczema outbreaks&#46; He was admitted to the hospital after developing erythroderma with lymphadenopathy &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; A skin biopsy confirmed the clinical suspicion of mycosis fungoides&#46; The complementary tests did not show clonality in peripheral blood or lymph nodes&#44; so the diagnosis of mycosis fungoides stage IIIa &#40;T4N1aM0B0&#41; was established&#46; Over the following days&#44; the patient developed malaise&#44; fever&#44; and hip pain&#46; Blood cultures were positive for <span class="elsevierStyleItalic">MSSA</span> and <span class="elsevierStyleItalic">Streptococcus pyogenes</span>&#46; Body CT showed an iliac abscess&#46; Endocarditis was discarded as the patient had a mechanical heart valve &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">There is little written in the literature about the risk of bacteremia and infectious complications in patients with extensive chronic dermatoses&#46; A large Indian retrospective study evaluated the etiology and frequency of sepsis in patients admitted to the dermatology unit<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a>&#46; Among 860 patients&#44; 4&#46;65&#37; developed sepsis&#46; Within these cases&#44; vesiculobullous diseases were the most frequent diagnosis &#40;42&#46;5&#37;&#41;&#44; followed by erythroderma &#40;25&#37;&#41;&#46; <span class="elsevierStyleItalic">Methicillin-resistant SA &#40;MRSA&#41;</span> was the most common organism&#44; but also <span class="elsevierStyleItalic">MSSA</span> was isolated in 8&#46;7&#37; of the patients&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Erythroderma may be a portal of entry to bacteremia as it involves an epidermal barrier dysfunction&#46; Also&#44; high-dose steroids and immunosuppressives are typically used in these patients&#44; which favor infections and might cover up symptoms&#46; Routier et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> describe 2 patients with psoas abscesses caused by streptococcal infection with a cutaneous portal of entry&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">On the other hand&#44; psoriatic erythroderma may be triggered by infections&#46; Green et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> report 5 patients with erythrodermic psoriasis and hidden SA bacteremia&#46; Skin manifestations only got better when the infection was controlled&#46; Although it is unusual&#44; bacteremia might have come from a primary abscess exacerbating skin lesions secondarily&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">SA colonization has been associated with increased BSA involvement in psoriasis<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> and cutaneous T-cell lymphoma &#40;CTCL&#41;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a>&#46; CTCL patients frequently present bacterial infections&#44; particularly SA&#46; Staphylococcal decolonization often results in clinically significant improvements<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The reason why abscesses in the iliopsoas are formed is not clear&#46; A lower limb or perineal wound could explain the predisposition for an abscess to appear in that area&#46; It is also a well-vascularized region where microorganisms could seed&#46; In addition&#44; elderly patients may suffer from osteoarthritis or trauma&#44; which predisposes them to infection&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The diagnosis is based on clinical symptoms and imaging tests&#46; CT and MRI are the gold standards&#44; but in the early stages&#44; they can present false negatives<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a>&#46; That is why it is important to have this diagnosis in mind and repeat imaging tests if necessary&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Treatment consists of broad-spectrum antibiotics and abscess drainage&#46; Surgical drainage is the traditional treatment&#44; but image-guided percutaneous drainage is an effective alternative&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In short&#44; erythroderma involves an epidermal barrier dysfunction that predisposes to infection and bacteremia&#46; Primary psoas abscess probably occurs as a consequence of hematogenous seeding&#46; Therefore&#44; erythroderma should be considered a risk factor&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">A high degree of suspicion is needed for an early diagnosis&#58; Thigh&#44; hip&#44; or back pain and bacteremia in an erythrodermic patient are mandatory to discard an iliopsoas abscess&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest</p></span></span>"
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