Background: Pure red cell aplasia is characterized by anemia, reticulocytopenia and diminished bone marrow erythroid precursors. It has multifactorial etiology and consequently several therapeutic interventions. Case: In August 2017, a young patient was diagnosed to have pure red cell aplasia. She was given immunosuppressive therapy for approximately two months but this treatment was stopped due to intolerance. Later on she developed herpes zoster infection that was treated with valacyclovir. Subsequently, it was noted that the patient became blood transfusion independent due to normalization of her hemoglobin and regeneration of the erythroid precursors in the bone marrow. Discussion: Varicella zoster virus behaves differently from other members of the herpes group of viruses such as cytomegalovirus and Epstein-Barr virus. Two retrospective studies, performed in patients with malignant hematological disorders and bone marrow failure, have shown that infection with the virus may cause stimulation of the three cell lines in the bone marrow and superior overall survival. Conclusion: The outcome of the patient presented confirms the findings of the two studies showing long-term beneficial effects of varicella zoster virus infections in immunocompromised individuals.

Varicella zoster virus (VZV), a double-stranded DNA virus, is a highly contagious human neurotropic virus that belongs to the alpha group of herpes viruses [1-4]. Primary VZV infection (chickenpox) occurs in childhood then the virus becomes latent in the nerve ganglia [1,5-7]. Reactivation of the virus may occur decades later and cause herpes zoster (HZ) which is manifested by a typical painful skin eruption that has characteristic dermatomal distribution [1,5]. Reactivation of VZV is usually predisposed to: old age; comorbid medical conditions such as diabetes mellitus, chronic obstructive airway disease, and end-stage renal disease; and immunosuppression due to malignancy, autoimmune disorders, immunosuppressive therapies, trauma, cytotoxic chemotherapy, hematopoietic stem cell transplantation (HSCT), and solid organ transplantation (SOT) [1,5-7].

Hepatitis C Virus (HCV) infection is usually treated with direct acting antivirals (DAAs) for 12 weeks. In treatment naive patients with genotype (GT) 1 infection without cirrhosis and baseline viral load < 6 million, 8 weeks of Ledipasvir/Sofosbuvir (LDV/SOF) is an option. Eight weeks with Glecaprevir/Pibrentasvir (GLE/PIB) is an option for patients with GT 1 through 6 without cirrhosis. Our objective was to evaluate achievement of Sustained Virologic Response (SVR) after 8 weeks of LDV/SOF or GLE/PIB in our HCV-infected veterans. Patients with HCV infection that received GLE/PIB or LDV/SOF for a planned 8 weeks of therapy in the past four years were reviewed (January 2015-September 2018). Treatment outcomes were evaluated through medical record review. Two hundred sixty-five veterans were initiated on 8 weeks of therapy with either GLE/PIB or LDV/SOF. Of these, 231 (87%) were initiated on 8 weeks of LDV/SOF and 34 (13%) were initiated on 8 weeks of GLE/PIB. The majority of patients had GT 1 (93%) infection. One hundred and ninety-five veterans who completed 8 weeks of LDV/SOF and 30 veterans on GLE/PIB had follow-up viral loads. The overall SVR was 95%. Treatment with GLE/PIB resulted in a higher SVR rate (100%) compared to LDV/SOF (95%). Elderly patients had similar SVR rates. Treatment with 8 weeks of DAA is effective in our veteran population and showed an SVR rate similar to literature reports. The SVR for patients treated with 8 weeks LDV/SOF was slightly lower than the SVR for GLE/PIB; however, the GLE/PIB population was smaller

Background: Like other viruses, the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) appears to be responsible for several autoimmune complications. The occurrence of autoimmune hemolytic anemia has been described in several case reports. This AIHA was also noticeable by the important number of blood transfusions required for COVID-19 (coronavirus disease 2019) patients. By investigating RBC coating autoantibodies, this article attempts to clarify the autoimmune aspect of the anemia in the context of SARS-CoV-2 infection. Results: A large population of COVID-19 patients selected at Saint-Luc University Hospital showed an average of 44% DAT positivity. In this population, the intensive care patients were more prone to DAT positivity than the general ward patients (statistically significant result). The positive DAT appeared « transmissible » to other RBCs via COVID-19 DAT-positive patient’s plasma. Conclusion: The strongest hypothesis explaining this observation is the targeting of cryptic antigens by autoantibodies in COVID-19 patients.

The insufficiency of interferon production and the cytokine imbalance in patients with atopic dermatitis, especially in combination with persistent herpes virus infection, has been identified. The expediency of the use of interferon inducer Cycloferon in the treatment of chronic atopic dermatitis has been shown.

Background:While recognition and documentation of true drug allergy is critically important, most physicians acknowledge that its prevalence is likely overestimated, often on the basis of historical, sometimes anecdotal evidence. Correct or not, once applied, drug allergy labels may result in altered, potentially inferior therapy, increased costs and prolonged hospitalisation. Objective:Estimate the point prevalence, accuracy and symptomatology of self-reported drug allergy in a typical, large NHS Acute Trust adult inpatient population. In the subset with penicillin allergy (PA), estimate additional management costs from the use of alternative antibiotics and readmission rates in the previous 5 years. Methods:Data on self-reported drug allergies were extracted from 440 adult inpatient prescription charts over a 4 month period. Where penicillin allergy (PA) was reported, alternative antibiotic regimens were recorded and their additional costs calculated. Hospital electronic records were used to assess readmission rates of PA patients. Results:194/440 inpatients (44.5%) reported at least one drug allergy. Antibiotic allergy was most commonly reported (51%), followed by analgesic (23%) and antiemetic (12%) allergy. PA accounted for 76% of reported antibiotic allergy. The commonest reported symptoms were cutaneous (42%) and gastrointestinal (18%). Where antibiotic therapy was required for patients with PA to manage acute infections, Ciprofloxacin, Clarithromycin, Teicoplanin, Clindamycin and Cefuroxime were the most commonly employed alternatives. Extrapolation of these figures to include the entire Trust inpatient population suggested that the use of alternative antibiotics in PA patients incurred additional annual expenditure of £268,000. Further, 87% of PA patients had been admitted more than once in the preceding 5 years, with 74% requiring further courses of antibiotics during these admissions. Conclusion:Self-reported drug allergy, and in particular PA, is common in hospital inpatient populations and, in addition to the potentially unnecessary hazards to individual patients resulting from the use of alternative antibiotics, results in a considerable additional financial burden to the healthcare system. This problem could be eliminated by the provision of a nationwide and equitable tertiary Allergy service.

Coronavirus infections have caused outbreaks in humans: SARS-COV ((Severe Acute Respiratory Syndrome) and MERS-CoV (Middle East Respiratory Syndrome) resulting in significant mortality and morbidity

Hepatitis A virus (HAV) infection is the commonest form of acute viral hepatitis all over the world. Complicated HAV cases had been reported with evolving presentations. This is a report of three cases of non-fulminant HAV infections annotating rare non hepatic sequalae.

Seizure is clinical manifestation of sudden disruption of the normal electrical activity of cortical neurons. The brain electrical activity is periodically disturbed, alteration in neural cell integrity, increase in firing impulses and spread to adjacent normal neurons result in temporary brain dysfunction with alterations in consciousness, behavior or motor function. It may be triggered by illness, infection, stress, stroke, brain tumor, or the underlying cause may not completely understand. Status epilepticus (SE) is a medical emergency and requires prompt diagnosis and treatment. Treatment includes general support measures, drugs to suppress epileptic activity and relieving the underlying condition. Refractory SE requires admission to an intensive care unit (ICU) to allow adequate monitoring and support of respiratory, metabolic and hemodynamic functions and cerebral electrical activity. For SE treatment, benzodiazepines are the first line antiepileptic agents, and if benzodiazepines fail to control seizures, Phenytoin is usually indicated; Phenobarbital or Valproate may also be considered. For refractory SE, Propofol and Thiopental represent first line agents after careful assessment of potential risks. In refractory SE, general anesthesia may be required. There is currently no unique consensus for definite treatment option of RSE. In this review, the management protocol of seizure, assessment, monitoring, and different alternative therapy would be discussed.

Objectives: The study aims to assess the knowledge, attitude and practices of physicians who deal with pediatric age group SSTIs in reference to the Infectious Diseases Society of America (IDSA) guidelines on this regard that was published in 2014. Background: Skin and soft tissue infections rank among the most frequent infections worldwide. It is estimated that over 11 million ambulatory healthcare visits occur each year in US for skin and soft tissue infections due to Staphylococcus aureus (S. aureus) alone. SSTIs are clinical entities of variable presentation, etiology and severity that involve microbial invasion of the layers of the skin and underlying soft tissues. SSTIs range from mild infections, such as pyoderma, to serious life-threatening infections, such as necrotizing fasciitis. One of the main challenges in managing SSTIs is to be able to identify those who need immediate inpatient intervention versus the more stable ones that can be manages in outpatient basis. In June of 2014, The Infectious Diseases Society of America (IDSA) released evidence based guidelines that has nicely covered all aspects related to the management of SSTIs. Method:An anonymous 20-item survey exploring knowledge, attitude and practices associated with diagnosis and management of skin and soft tissue infection was distributed to physicians of different levels of expertise (from residents to consultants) in the departments of Pediatrics, Emergency Medicine and Family Medicine in different governmental facilities in Al-Ain city which is one of the major cities in United Arab Emirates.

Background: Asthma is the most common chronic respiratory disorder in childhood. Asthmatic attacks are described and classified according to the type of wheezing to Non –atopic and Atopic asthma (IgE mediated wheezing). The aim of this review is to determine the onset of clinical diagnosis in relation to clinical presentation of asthma in children and obstacles related to delay of Asthma diagnosis. Methods: This review highlights the results of studies done regarding clinical diagnosis in relation to clinical presentation and of asthma in children. An extensive search has been conducted for researches about asthma in children. This search based on the publications posted on the National Center for Biotechnology Information PubMed or by Google Scholar. Key words used for the research: Asthma, clinical diagnosis, children. Results and Conclusion: Diagnosing asthma in young children is difficult because children often cough and wheeze with colds and chest infections, but this is not necessarily asthma. Miss diagnosis of asthma in children occurs when physicians diagnose patients with asthma from the clinical diagnosis in the first attack without excluding other asthma mimickers which can be any other respiratory problem. There is over-diagnosis of asthma due to the symptoms which mimic other respiratory infections. First episodes of cough, runny nose and fever that happen in cold/flu season- fall/winter/early spring is likely not asthma. If the child has several more episodes of wheeze and cough, it is likely to be asthma. Since there is no diagnostic test available for children younger than 6 years of age, making a diagnosis in this age group is more difficult than in older children. Over the age of about 6 years it is possible for a child to have a spirometer test

Asthma is a chronic respiratory disease characterized by chronic airway inflammation. Common manifestations of asthma include wheezing, chest tightness, cough, shortness of breath. Diagnosis of asthma requires clinical documentation of respiratory symptoms, exacerbation of symptoms following exposure to triggers, as well as demonstration of expiratory airflow obstruction. Wheeze is a continuous sound, lasting longer than 0.25 s that is produced by oscillation of opposing airway walls [1,2]. Wheezing, although a typical symptom of asthma, can also be caused by other diseases. Apart from asthma, wheezing can be due to extra-thoracic upper airway obstruction, intrathoracic upper airway obstruction, lower airway obstruction. Benign multimodal goiter is a common disease, that rarely causes upper airway obstruction. Retrosternal goiter should be taken into account the differential diagnosis of upper airway obstruction [3]. The respiratory symptoms of a retrosternal goiter may be masked for years due to the slow growth of the goiter. Patients commonly complain of respiratory symptoms if tracheal diameter is narrowed more than 50% from the normal size. Respiratory symptoms may be suddenly precipitated by spontaneous or traumatically induced bleeding into the substernal goiter, as well as by tracheal infections [4]. Clinical management of this condition is really challenging. Diagnosis is also not straightforward, as clinical suspicion is needed. There are cases of retrosternal goiter mimicking asthma that remain undiagnosed for many years. Retrosternal goiter should be taken into account in the differential diagnosis of patients diagnosed as suffering from asthma, and presenting no improvement despite medical therapy. In addition, it should be taken into account that sudden gland enlargement due to hormonal changes might lead to life threatening upper airway obstruction with clinical picture similar to bronchial asthma attack [5]. In a recent very interesting case report, the authors present a case of a pregnant woman in the second trimester who presented with an acute airway obstruction due to the enlargement of a retrosternal goiter [3]. Goiters are the more common masses of the superior mediastinum [6,7]. Commonly, retrosternal goiter is due to the extension in the thorax of a cervical goiter. However, rarely, it may represent primary disease due to the growth of ectopic thyroid tissue. In addition, retrosternal goiter may develop in patient submitted to thyroidectomy due to cervical multinodular goiter [8]. Although retrosternal goiters are commonly asymptomatic, symptoms may include dyspnea, stridor, hoarseness, dysphagia, superior vena cava syndrome, transient ischemic attacks, cerebral edema, Horner’s syndrome, and thyrotoxicosis [4]. Diagnosis could be verified by neck and chest radiography, thorax CT and MRI. Chest radiography commonly shows a widened mediastinum with a superior mediastinal mass causing compression of the trachea as well as deviation of the trachea to the right. Mediastinal computed tomography reveals a mass that is extension of the thyroid gland. The presence of respiratory symptoms in a patient with retrosternal goiter is an indication for surgery. The majority of retrosternal goiters can be approached through a cervical approach [9,10].

Cystic fibrosis (CF) is a hereditary syndrome composed of exocrine gland dysfunction involving multiple systems which if untreated may result in chronic respiratory infections, pancreatic enzyme deficiency and failure to thrive. The association between CF and other inherited diseases or congenital anomalies is rare. We describe a rare case of CF with concomitant congenital adrenal hyperplasia (CAH). 21- Hydroxylase deficiency accounts for most CAH cases. Varity in clinical phenotypes depends on the amount of enzymatic activity which in turn depends on different combination of gene mutations. The genes of CAH and CF are located in different locations. The chance of these diseases coexisting in our patient would be a rare combination. However, such a case will be more frequent in our population than others because of consanguineous marriage and common ancestors. There are diagnostic difficulties, similarities and contradictions between two diseases and they are pointed out.

A 64-year-old woman was referred to our hospital due to progressive dypnoea for the past week, combined with fever and type 1 respiratory failure. White blood cell count and procalcitonin level were normal. The Chest X-ray showed bilateral disseminated pulmonary infiltrates. Within the next 24 hours the patient developed a severe ARDS. A first diagnostic work-up for typical and atypical pathogens as well as serological tests for CMV, RSV, HIV and HSV were negative. Analysis of a second bronchoalveolar lavage fluid revealed Pneumocystis jiroveci DNA. The patient was successfully treated with trimethoprim-sulfamethoxazole and off label use with caspofungin. The cause of the infection was a six week treatment with dexamethasone. The patient developed a toxic epidermal necrolysis during further course, but completely recovered. Pneumonia with Pneumocystis jirovecii must also be taken into account in non-HIV patients, whenever there are any indications that cellular immunity may be depressed.

Objectives: As the cancer patients are at higher risk of premature deaths due to candidemia. So, the present study aims to evaluate the predictors of candidemia along with its outcomes among hospitalized adults and pediatric cancer patients. Methods: A retrospective study was conducted at a tertiary care cancer hospital in Lahore, Pakistan. The data was collected from the medical records of all the patients who were found positive for Candida species between 1st January 2017 and 31st June 2017. Data were analyzed by using Statistical Packages for Social Sciences (IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) and Microsoft Excel (MS Office 2010). Results: Overall, 135 patients were detected with candidemia. Based on blood culture test results, it was found that out of 100 cultures positive for any microorganism there were 2 cases of candidemia. Multivariate analysis revealed that hematological malignancies (AOR: 2.1), and shock (AOR: 9.1) were significantly associated with high risk of mortalities during the index hospitalization, while risk of mortality among cancer patients suffering from Candida albican infection (AOR: 0.47) and those who were administered with antifungal agent after sensitivity report of the fungal culture (AOR: 0.2) was significantly less. Also, there was no significant association of empiric therapy of antifungal agent with the risk of mortality before a positive culture found (p>0.05). Conclusion: Although, no risk factor was found to be associated significantly with candidemia among cancer patients. But hematological malignancies, non-albican candidemia and shock were predictors of higher risk mortality during index hospitalization.

Septic Iliac vein thrombophlebitis with associated psoas abscess is a rare and severe entity, which diagnosis is challenging when no risk factor is clearly present. We are presenting a case of severe septic cavitary pulmonary emboli complicated with Acute Respiratory Distress Syndrome (ARDS) that evolved rapidly to respiratory distress and multi organ failure. A 61-year-old Hispanic male, had multiple emergency department visits due to back pain, being most of them intramuscular pain medications and steroids. In the history, he had back pain that worsened accompanied by poor mobility, generalized malaise, fever and chills. Computed tomography (CT) scan showed a paravertebral psoas abscess with L5 - S1 diskitis/spondylitis inflammatory changes, which was then later evidenced by a gallium study. Further imaging studies were done, showed bilateral cavitary lung lesions, consistent with septic emboli. Subsequent blood cultures were positive for Methicillin Resistant Staphylococcus Aureus (MRSA), for which a successful combined therapeutic regimen was used. Transthoracic and transesophageal echocardiogram were not suggestive of endocarditis. Staphylococcus aureus (SA) bacteremia is one of the most common serious bacterial infections with a high risk of metastatic complications, which makes this pathogen a unique one. The combination of factors iliac vein thrombophlebitis, psoas muscle abscess, diskitis/spondylitis with ARDS makes cavitary pulmonary disease a challenging perspective. After a 6-week antimicrobial treatment, full anticoagulation, his clinical condition and image findings improved, and he was recently admitted for physical rehabilitation. Major vessels thrombophlebitis should always be considered, when primary source of septic pulmonary emboli is not clear. This case illustrates the complexity of illness and complications that may arise from a source of infection as the one in this patient. Further therapeutic strategies were tailored accordingly.

The onset of the pandemic has caused widespread concern about the rapid spread of the infection and serious concern about the lack of specific treatment for it. Calls and demands for strict compliance with sanitary and anti-epidemic measures, a sharp reduction in direct contacts and movements of people with the introduction of quarantine measures in large regions and even countries have become a familiar modern reality. All these efforts do not yet allow us to see and feel their positive results, and the next wave of infection destroys hopes for the likelihood of achieving rapid and complete success in the fight against this evil. At the same time, a detailed analysis of the material accumulated during this period allows us to identify the most problematic links in the process of diagnostics and providing care to such patients and to note the reasons that require priority solutions.

Owing to the ever westernizing lifestyles in developing countries like India, the escalation of oral cancer patients are in need of urgent plan of action. With tobacco being the commonest cause for causation of oral cancer, Global Adult Tobacco Survey, 2016-17 revealed that almost 28% of whole population of India is consuming tobacco in either smoking or smokeless form. With these increasing numbers, the expected death toll to be expected to touch 1-2 million mark by the year 2035 [1]. Although, the current Onco-medicine fraternity excels in rendering care to oral cancer patients in the form of surgeries, chemotherapy and radiation-therapy. Often, these treatment modalities impart some unwanted adverse effects like, docetaxel (DCT) is known for its hepatotoxicity [2,3] whereas, one of the commonly used cisplatin (CIS) presents with nephrotoxicity, neurotoxicity, bone marrow suppression and vomiting [4,5]. Literature suggests of many non conventional medicaments being tested in past for their anti onco-genic effect, where few being effective and others being questionable ones. Chlorhexidine being one among them showing some how promising anti onco-genic activity with feeble amount of studies being conducted in past. Chlorhexidine, one of the most commonly prescribed mouthrinse in the field of dentistry, with varying concentrations of 0.12% and 0.2% concentrations. Although, apart from being broad spectrum antibiotic, its capability to dismantle the protein – protein bond between anti – apoptotic Bcl-2 family protein Bcl-xL and its pro – apoptotic binding partners [6]. The current study was conducted on three cell lines of squamous cell carcinoma (SCC-4, SCC-9, SCC -15) and two pharynx carcinoma cell lines (FaDu and Detroit 562). The compounds induced apoptosis through mitochondria dependent apoptotic pathway in oral tumour cell lines. Another study conducted to assess the similar anti – oncogenic activites of chlorhexidine mouthrinse along with cranberry [7]. It was evident from results that, with increasing concentrations of chlorhexidine mouthrinse, there was increase in mean percent growth inhibition. The authors concluded saying, chlorhexidine has showed both anti cancerous as well as anti bacterial activity required to tackle common oral infections, part of common anti cancer therapy. Fernando Martínez-Pérez et al (2019) conducted study, where antitumor activity of Lipophilic Bismuth Nanoparticles (BisBAL NPs) and chlorhexidine on human squamous cell carcinoma was assessed using energy dispersive X – ray spectroscopy in conjunction with scanning electron microscopy (EDS-SEM). Study revealed, BisBAL NPs and chlorhexidine both showed cell growth inhibition on both cancer cell line (CAL-27) and human gingival fibroblasts (HGFs). Although, chlorhexidine showed non specific cytotoxicity for both tumoral and non tumoral control cells. The suggestive mechanism of action might be loss of cell membrane integrity [8]. Although Eliot MN (2013) conducted study, to assess the risk of head and neck squamous cell carcinoma secondary to use of alcohol containing and non alcoholic mouthwashes including chlorhexidine. The study was concluded with an assumption based on chlorhexidine mouthwash alters the oral flora [9], thus resulting in increasing risk exponentially through diverse change in oral bacteria and altered immune response with contribution towards genesis or promotion of cancer [10]. On the contrary, alcohol consumption and smoking are predisposing factors towards upper digestive tract cancer. The main causative factor being the first metabolite of alcohol, acetaldehyde. And much higher levels are derived from oral bacteria and thus, same can be altered in favour through usage of chlorhexidine mouthwash, to avoid excessive production of acetaldehyde intra orally. In conclusion, chlorhexidine mouthwash has been into dental practice since long and the role it plays in either ways has to be assessed by a multi dimensional study with cell lines including that of control to derive better compared conclusions.

Introduction: Primary infection with varicella-zoster virus (VZV) results in chickenpox, characterized by viremia with a diffuse rash and seeding of multiple sensory ganglia, where the virus establishes lifelong latency. Herpes zoster is caused by reactivation of latent VZV in cranial-nerve or dorsal-root ganglia, with spread of the virus along the sensory nerve to the dermatome. Both entities have a benign clinical course in immunocompetent and young individuals. Although Herpes zoster virüs may result in Ramsey Hunt sendrom, it may rarely cause peripheral facial paralysis in the course of varicella. Case report: A 4-year-old girl patient was admitted to the ear, nose, and throat clinic with a complaint of a rash over the body with vesicles and pustules a few days. She had left peripheral facial palsy about 2 days ago. In a general clinical examination, a few macular lesions, probably residues of vesicles, and fluid-filled blisters and pustules were observed on the back, chest, abdomen, upper, and lower limbs. She had remarkable left peripheral facial palsy. Her facial palsy was assessed as a grade II using the House-Brackmann Score. Otoscopic examination was normal and otalgia and auricular vesicle was absent. 1 mg/kg/day prednisone and 30 mg/kg/day acyclovir therapy were given to the patient due to the peripheral facial nerve palsy involvement of the VZV infection. Complete remission was achieved at 1 month after treatment. Conclusion: Varicella-zoster virus (VZV) is one of eight herpes viruses known to cause human infection and is distributed worldwide. While the results of bell palsy are good, facial paralysis results during viral infections are severe. Cranial nerve involvement secondary to viral infection should be followed closely. The current standard of care for treatment is acyclovir and prednisone. Thus early treatment can be started in the face of developing complications and possible mortality and morbidity can be prevented.

Introduction: Necrotizing Fasciitis (NF) is a rapidly progressing, severe suppurative infection of the superficial fascia and the sorrounding tissues that may lead to necrosis, septic shock and death if left untreated. Facial NF is rarely seen and symptoms may be non-specific at the onset and depend on the origin site and the stage of the disease, making it difficult for diagnosis. Materials and Methods: A systematic review was done following the PRISMA guidance. PubMed database was searched for case reports published between January 2007 and March 2017. Full text articles were obtained and assesed for relevance. Data extraction was performed as an iterative process. Results: A total of 24 articles, describing 29 adult patients with facial NF were included. Facial NF was more common in males. Skin trauma was the most frequent mechanism of lesion and diabetes mellitus was the most common associated systemic disorder. Periorbital area was the most affected area. In order of appereance, swelling and pain were the most common initial clinical manifestations. Group A Streptococcus was the most frequent microorganism isolated. Advanced airway management was needed in more than 50% of the cases and surgical management was done in 90% of the cases. Conclusions: Practitioners should be aware of its existance, epidemiology, etiology, risk factors and initial clinical manifestations to develop a high index of suspicion, to order studies that may discard or confirm the diagnosis, and to offer prompt treatment to preserve patient’s life and reduce the disfigurement and disability that it may cause.