Infection is the primary source of mortality in burn patients. One of the main treatment methods of burn wound infections is topical antimicrobial therapy, in which drugs have to permeate a dead tissue called eschar. Unfortunately, most antimicrobial agents can not permeate eschar in therapeutic levels. Surprisingly, permeation properties of this barrier and effects of chemical or environmental conditions on it, including hydration level which is the subject of the present investigation, is not thoroughly studied as yet. Here, permeation of silver sulfadiazine (SSD), the most frequently used topical agent in burn management, from its’ 0.6 mg/ml solution through human third-degree burn eschar was studied in vitro at different hydration levels of fully-hydrated, semi-hydrated and dry eschar. The experiments were performed at 32°C, using Franz-type diffution cells. Hydration level was adjusted by controlling the contact condition of eschar tissue with an aqueous medium. Results showed that hydration can severely affect permeation of SSD through the burn eschar. Permeation of SSD through fully-hydrated tissue was about 20 times more than that of semi-hydrated samples. Permeation of SSD through dry eschar was initially (up to 3 h) more than those of semi- or fully hydrated tissues, but it ceased and reached a plateau at this time point, while for the other systems continued and became more than that of the dry eschar at later stages. The cumulative amount of drug permeated through the fully-hydrated tissue in 8 h was about 30 times more than that of the dry eschar. Our results showed that hydration can clearly improve permeation of SSD and possibly other drugs through third-degree burn eschar. A property which could easily change during patient management, e.g., by covering, washing, or application of occlusive formulations.

A 47-year-old Iranian man presented with a 3-month history of painful extremities lesions. The lesions began with an erythematous papule that progressively enlarged and ulcerated. His left calf was the first site of involvement. At the time we visited him, there were necrotic painful violaceous skin ulcers with a symmetrical distribution involving lower parts of distal limbs and his left thigh.He had a 10-year history of hypertension and a 5-month history of peritoneal tuberculosis. Recently, he received dialysis due to End Stage Renal Disease (ESRD). He had received medications such as Furosemide, Omeprazol, Isoniazid, Ethambutol, Rifampin and Pyrazinamide from 5 months ago. Physical examination showed a cachectic middle aged man in distress because of severe pain.His abdomen was distended, but no ascitis or organomegaly was detected. The pedal pulse was absent. Large multiple ulcers with surrounding erythema and induration, some with dark eschar, were seen on his calves, thighs and left hand (Figure 1). Some of his toes and two fingers of his left hand were gangrenous. A hand x-ray and a skin biopsy from the newest lesion were obtained. Some soft tissue opacities were seen in the hand x-ray (Figure2).

Antimicrobial therapy remains to be the most important method of wound infection treatment. Systemically administered antimicrobials may not achieve therapeutic level in wound. On the other hand, in the absence of surgical debridement (due to any reason), most topically applied antimicrobials cannot penetrate the wound in therapeutic amount due to the presence of eschar. Burn eschar is a proteinous structure with some lipid components in which proteins seems to play an important role in the barrier effects of eschar. Therefore, in this study the effect of protein-acting enhancer (trypsin) on permeation of hydrophilic model drug (clindamycin phosphate) was investigated.To perform this investigation, permeation of saturated clindamycin phosphate was studied at 32oC through trypsin-treated and untreated eschar samples for 12 h using home-made static diffusion cells. Third-degree burn eschar samples were separated at the time of surgical debridement (7-14 days post burn) from burned patients. Before each experiment, eschar was hydrated for 12 h and samples were then treated with trypsin solution (1%, w/v) for 4 and 24 h. Clindamycin was measured by a HPLC method developed here.Results showed that after trypsin-treatment for 4 and 24 h, clindamycin phosphate permeation flux was increased significantly by about 1.5 and 2 times and permeation lag-time was decreased by about 2 and 1.3 times respectively.The present results show that permeation of drugs through burn eschar can be increased considerably by trypsin.

Objectives: To analyze the clinical characteristics of scrub typhus (ST) initially misdiagnosed as Kawasaki disease (KD) in children.Methods: This study was conducted through a review of medical records of children with ST from March 2005 to June 2015.Results: Among182 incomplete KD patients, 11 patients were ST. Red lips, strawberry tongue, and BCGsite redness were not reported.Presence of eschars was reported in 5 patients. Group 1 patients (n=6) were initially treated by using intravenous immunoglobulin (IVIG) and amongthem, one patient had an eschar after IVIG use. Group 2 patients (n=5) were also initially diagnosed as KD but were not treated because eschar was detected in four patients before use of IVIG. One patient had no eschar but had a positive serologic test before IVIG use.Conclusions: When children have symptoms similar to KD but without red lips and strawberry tongue, clinicians should search for an eschar and perform serologic tests for ST.

Objective: To study the clinical profile and complications of childhood scrub typhus.Methods: Prospective observational study of 66 children with scrub typhus, admitted to a tertiary hospital in north India, during the period between January 2011 and December 2012. The diagnosis was confirmed by serology.Findings: All children presented with fever. Other common symptoms were vomiting (56%), facial swelling (52%), cough (35%), abdominal pain (33%), breathlessness (29%) and decreased urine output (29%). High grade fever (>101 oF) was recorded in 91% of children. Other common signs were hepatomegaly, splenomegaly, edema, tender lymphadenopathy and hypotension, observed in 82%, 59%, 39%, 38% and 36% of cases, respectively. An eschar and a maculopapular rash each were observed in 20% of patients. Meningoencephalitis (30.3%), severe thrombocytopenia (27.2%), shock (25.8%), acute kidney injury (16.7%) and hepatitis (13.6%) were the most common complications observed in these children. Other common complications were acute respiratory distress syndrome, respiratory failure requiring ventilation, bronchopneumonia and myocarditis. Ninety percent of children became afebrile within 48 hours of initiating an appropriate antibiotic. Median time to defervescence was 22 hours. The overall mortality rate was 7.5%. Causes of death were refractory shock, meningoencephalitis, acute respiratory distress syndrome, bronchopneumonia, acute kidney injury and myocarditis.Conclusion: Pediatricians should keep a high index of suspicion for scrub typhus in any febrile child having a maculopapular rash, hepatosplenomegaly, tender lymphadenopathy, thrombocytopenia and features suggestive of capillary leak. Pending serological confirmation, empirical therapy with doxycycline or azithromycin should be started, as delay in treatment would result in life threatening complications.

BACKGROUND Chronic wounds affect mainly the productive age group in developing countries and stretch the limited healthcare facility. We aimed to establish the efficacy or otherwise of pawpaw dressing in management of common forms of wounds in resource-poor settings using the Nigerian pawpaw in humans. METHODS This study was a prospective research carried out at Alex Ekwueme Federal University Teaching Hospital Abakaliki Nigeria between September 2019 and August 2020 using patients with lower extremity wounds. Thirty patients who had lower extremity wounds that required debridement were enrolled in the study after giving consent. They had wound dressing with unripe pawpaw as an enzymatic debriding agent to evaluate the rapidity of eschar separation and bacterial clearance. The data obtained with a proforma were analyzed using IBM SPSS. RESULTS There were 16 males and 14 females with an average wound size of 127. 13+ 103cm2. Eschar separation occurred earliest after 3 d of dressing and the latest after 14 d with a mean period of 5. 5+ 2. 255 days. A case had negative bacterial culture on the first test. Others had a variable period of clearance with a maximum of 18 d and a mean of 6. 73+3. 750 days. Both eschar separation and bacterial clearance correlated positively with the wound size. CONCLUSION Wound bed preparation with unripe pawpaw dressing showed promising outcomes with rapid eschar and slough separation, and bacterial clearance resulting in a faster wound healing. This is recommended for wounds needing debridement in which the patients are not fit for anesthesia or could not afford the cost of surgery.

Scrub typhus is an acute, febrile zoonosis caused by an obligate intracellular bacterium Orientia tsutsugamushi. The clinical manifestations of the disease range from subclinical to fatal organ failure. The common symptoms are fever, chills, headache, myalgia, dry cough, lymphadenopathy, and gastrointestinal disturbances. The presentation with complications is usually due to delay in diagnosis and treatment. We report three cases of scrub typhus that presented with features of meningo-encephalitis, which is very unusual, and all patients recovered with empirical doxycycline treatment.