Shewanella putrefaciens is as yet rarely responsible for clinical syndromes in humans. However, a case involving multiple organs in an elderly male under treatment with appropriate steroids confirms that attention should be devoted to unusual pathogens. CASE REPORTAn 87-year-old Caucasian male who had come back a few days before from holidays on the Adriatic shore was admitted because of shivering, fever up to 39.8°C, and erysipelas of the left forearm. He complained of malaise, extreme weakness, and severe pain at the upper left extremity. No other relevant symptoms were present. There was a history of "rheumatic myalgia" (not well diagnosable) for which he was on long-term, low-dose methylprednisolone (4 mg once daily); he denied other previous illnesses of note and regular consumption of any drugs.On exam, he presented as an obese man with a typical Cushing-like face and was febrile (39°C) but hemodynamically stable. A 1.5-cm-long cutaneous-subcutaneous wound was present on the skin near the left elbow, together with erysipelas affecting the whole left forearm. Small-bubbled rattling noises were heard at the level of the left pulmonary basis. In view of the fever, immediate blood (three sets each in aerobic and anaerobic bottles) (BD BACTEC, Benex Ltd., Shannon, Ireland), urine, and stool cultures were taken. Wound exudate was not cultured, nor was skin biopsy performed. Hematological investigations revealed a white cell count of 13.9 ϫ 10 9 / liter, a hemoglobin level of 14.0 g/dl, and a platelet count of 167 ϫ 10 9 /liter. C-reactive protein was at 13.5 mg/dl (normal range, 0 to 0.5 mg/dl), and the erythrocyte sedimentation rate was 37 mm (normal range, 0 to 10 mm). Chest X-ray film showed a segmental infiltrate in the left lower lobe very close to the diaphragm muscle and consistent with pneumonia. No sputum cultures were obtained, and the stable general conditions of the patient suggested delaying a bronchoscopy in order to recover lung aspirate. The patient was given empirical antimicrobial therapy with intravenous

The burden of risk factors for candidemia was different between medicine patients and those in other wards. Despite the lower severity of candidemia in medicine patients, their mortality turned out to be higher than in surgery or ICU patients. Awareness of the best management of candidemia should be pursued, especially in medicine wards.

SummaryBackgroundDrug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms (DIHS/DRESS) is a rare and severe adverse drug reaction with an associated mortality of 10–20%. Clinical worsening despite discontinuation of the culprit drug is considered a characteristic feature of DIHS/DRESS. Besides the early recognition of the syndrome and discontinuation of its causative drug, the mainstay of treatment is systemic corticosteroids. Nevertheless, treatment of severe DIHS/DRESS is not well defined, as corticosteroids may sometimes not be effective, and decreasing the dose may be associated with flaring of the disease.Case ReportA 38-year-old woman with high fever, malaise, abdominal pain, rash, and elevated liver enzymes received immediate high-dose N-acetylcysteine, because acetaminophen hepatotoxicity was suspected. N-acetylcysteine administration was associated with a significant clinical improvement. However, within the next week DIHS/DRESS syndrome was diagnosed, which explained all the symptoms, and which was subsequently treated with prednisone and valganciclovir.ConclusionsNew options necessary to improve treatment of severe DIHD/DRESS have to consider its sequential pathogenetic mechanisms. N-acetylcysteine might neutralize the drug-derived reactive metabolites, which are responsible for protein adduct formation and specific T cell stimulation, and replete the glutathione stores that counterbalance oxidative stress. Prednisone might inhibit lymphoproliferation and valganciclovir might prevent complications related to HHV-6 reactivation. We therefore propose the unprecedented combination of N-acetylcysteine, prednisone and valganciclovir as a treatment option for DIHS/DRESS.

COVID-19 is characterized by a severe pulmonary disease due to severe acute respiratory syndrome (SARS)-CoV-2 infection. For clinicians involved in the management of patients with chronic autoimmune diseases the risk linked to the conditions itself and to drug-induced immunosuppression during the COVID-19 pandemic is a major topic. Pemphigus is a rare autoimmune blistering disease (AIBD) of the skin and mucous membranes caused by autoantibodies to desmosomal components, desmoglein 1 and 3. Among immunosuppressant therapies, rituximab (RTX) is considered a highly effective treatment with a favorable safety profile, but it induces a prolonged B-cell depletion that can lead to higher susceptibility to infections. For this reason, concerns about its use during the pandemic have been raised. We describe a case of a pemphigus patient in which RTX-induced B cell depletion led to the severe inflammatory phase, whereas corticosteroid treatment allowed a favorable outcome.

<b><i>Introduction:</i></b> Being elderly is a well-known risk factor for candidemia, but few data are available on the prognostic impact of candidemia in the very old (VO) subjects, as defined as people aged ≥75 years. <b><i>Objective:</i></b> The aim of this study was to assess risk factors for nosocomial candidemia in two groups of candidemia patients, consisting of VO patients (≥75 years) and adult and old (AO) patients (18–74 years). In addition, risk factors for death (30-day mortality) were analysed separately in the two groups. <b><i>Methods:</i></b> We included all consecutive candidemia episodes from January 2011 to December 2013 occurring in six referral hospitals in north-eastern Italy. <b><i>Results:</i></b> A total of 683 nosocomial candidemia episodes occurred. Of those, 293 (42.9%) episodes were in VO and 390 (57.1%) in AO patients. Hospitalization in medical wards, chronic renal failure, urinary catheter, and peripheral parenteral nutrition (PPN) were more common in VO than in AO patients. In the former patient group, adequate antifungal therapy (73.2%) and central venous catheter (CVC) removal (67.6%) occurred less frequently than in AO patients (82.5 and 80%, <i>p</i> &#x3c; 0.002 and <i>p</i> &#x3c; 0.004, respectively). Thirty-day mortality was higher in VO compared to AO patients (47.8 vs. 23.6%, <i>p</i> &#x3c; 0.0001). In AO patients, independent risk factors for death were age (OR 1.04, 95% CI 1.00–1.09, <i>p</i> = 0.038), recent history of chemotherapy (OR 22.01, 95% CI 3.12–155.20, <i>p</i> = 0.002), and severity of sepsis (OR 40.68, 95% CI 7.42–223.10, <i>p</i> &#x3c; 0.001); CVC removal was associated with higher probability of survival (OR 0.10, 95% CI 0.03–0.33, <i>p</i> &#x3c; 0.001). In VO patients, independent risk factors for death were PPN (OR 3.5, 95% CI 1.17–10.47, <i>p</i> = 0.025) and hospitalization in medical wards (OR 2.58, 95% CI 1.02–6.53, <i>p</i> = 0.046), while CVC removal was associated with improved survival (OR 0.40, 95% CI 0.16–1.00, <i>p</i> = 0.050). <b><i>Conclusion:</i></b> Thirty-day mortality was high among VO patients and was associated with inadequate management of candidemia, especially in medical wards.