Beta-hemolytic streptococci (BHS) are the most common causative agents of perianal streptococcal dermatitis (PSD). This study evaluates the distribution of BHS isolates in perianal bacterial cultures. We retrospectively reviewed microbiological results for perianal BHS that were isolated in our laboratory between 2006 and 2015. We identified a total of 105 BHS isolates from rectal swabs and swabs of clinically intact perianal skin. The majority of BHS were of group A (GABHS) (73/105; 69.5%), followed by group B BHS (GBBHS) (27/105; 25.7%), and non-group A or B BHS (5/105; 4.8%). The distribution of GABHS was age-specific, with the majority of GABHS obtained from young children. All BHS isolates were susceptible to penicillin. GABHS were universally susceptible to clindamycin, whereas 1.4% were resistant to erythromycin. GBBHS were resistant to erythromycin and clindamycin in 14.8% and 7.4% of cases. In addition, we wanted to emphasize the importance of correct diagnosis of PSD. Hence, we provide a review of protocols that can decrease the time to diagnosis and treatment of PSD, reduce patients' discomfort, and prevent unnecessary diagnostic procedures.

Hand, foot, and mouth disease is a highly contagious disease that predominantly affects children under the age of five. The illness is much less common in adults and often presents with atypical skin lesions. Here we describe the case of a 19-year-old healthy, immunocompetent male patient with atypical clinical presentation, with a macular rash on the scalp, palms, soles, and shins, and with minimal lesions in the oral cavity. The diagnosis of hand, foot, and mouth disease was confirmed by isolation of coxsackievirus A6 from a vesicle smear obtained on the right sole. The skin lesions resolved spontaneously in 1 week. This case emphasizes the underestimated fact that hand, foot, and mouth disease can also occur in adults, in either typical or frequently atypical form, and it highlights the role of coxsackievirus A6. Together with the case presentation, a review of the literature describing the disease in adults is presented.

Necrotizing stomatitis is a rare, acute-onset disease that is usually associated with severely malnourished children or diminished systemic resistance. We describe a 1-year-old girl who developed necrotizing stomatitis, vasculitic rash, skin desquamation on the fingers and toes, and persistent hypertension after serologically confirmed SARS-CoV-2 infection. Her laboratory investigations revealed positive IgG anticardiolipin and IgG anti-β2 glycoprotein antibodies, and biopsy of the mucosa of the lower jaw showed necrosis and endothelial damage with mural thrombi. Swollen endothelial cells of small veins in the upper dermis were confirmed also by electron microscopy. As illustrated by our case, necrotizing stomatitis may develop as a rare complication associated with SARS-CoV-2 infection and can be considered as a part of the clinical spectrum of COVID-19 vasculopathy. The pathogenic mechanism could involve a consequence of inflammatory events with vasculopathy, hypercoagulability, and damage of endothelial cells as a response to SARS-CoV-2 infection.

Case presentationA 57-year-old male patient presented to our clinic in September 2021 with five large painful ulcerated lesions on his lower back (Fig. 1), shoulder (Fig. 2), head, right hip, and nasal septum. The first lesions appeared a year earlier, as pustules, and in later months they grew and eroded, forming ulcers with a purulent discharge. He was prescribed various topical antibiotic and antimycotic creams by a general practitioner, which did not result in improvement. He was first referred to a dermatologist in November 2020. A bacterial swab of the ulcer was negative. A skin biopsy suggested the possibility of pyoderma gangrenosum (PG) due to extensive ulceration with undermined edges and suppurative inflammation with multinucleated giant cells in the ulcer base (Fig. 3). Bacterial and fungal stains were negative, but additional microbiological tests were performed to confirm or exclude the possibility of PG. He was prescribed topical antibiotics (mupirocin and clindamycin) and an antiseptic lotion. After the biopsy, the wound initially healed completely, but after a few months two new growing papules formed under the scar, forming an ulcer larger than the previous one.Nasal symptoms appeared simultaneously with skin lesions. First a clear nasal discharge was present, which then became green and partially bloody. Bumps formed on the nasal septum and turned into an erosion. He was referred to an otorhinolaryngologist in December 2020, who described an extensive perforation of the anterior nasal septum measuring 2.5 cm and some crusts in both nostrils. A biopsy of the lesion showed nonspecific granulations adjacent to the ulceration. A swab of the nasal erosion was positive for Staphylococcus aureus, sensitive to all antibiotics tested. He was prescribed a 2-week course of systemic ciprofloxacin.In January 2021 he was referred to a rheumatologist. Clinical history for rheumatologic diseases was negative, except for brief morning stiffness, but he mentioned that he had unintentionally lost 4 kg in the previous 3 weeks. Routine laboratory tests showed only mildly raised C-reactive protein (CRP, 24 mg/l), erythrocyte

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