Viper envenomation typically presents with prominent local manifestations, including pain, edema, ecchymosis, cellulitis, and tissue necrosis. Severe systemic toxicity in the absence of significant local signs is uncommon. We report an atypical case of a viper envenomation in a 50-year-old male who presented with minimal local manifestations but rapidly developed life-threatening systemic complications. The 20-min whole-blood clotting test was non-clotting on admission. Despite prompt administration of polyvalent anti-snake venom (ASV) and symptomatic management, his condition progressively deteriorated. Non-contrast computed tomography of the brain on day 4 revealed an acute intracerebellar hemorrhage, which showed progressive enlargement on subsequent imaging on day 6, with tonsillar herniation. On the eighth day, he developed rapid hemodynamic deterioration and succumbed. At autopsy, two puncture wounds with mild discoloration were identified on the left foot, without significant local tissue reaction. Internal examination revealed a softened, edematous brain with hemorrhage involving the right cerebellar hemisphere and extending to the base of the skull. The snake, reportedly referred to by the patient as "Bandi," was presumptively identified as Echis carinatus sochureki, a subspecies of the saw-scaled viper commonly seen in the Thar Desert. The cause of death was given as intracranial hemorrhage and its complications secondary to venom-induced consumption coagulopathy (VICC) following vasculotoxic snake envenomation. This case highlights an atypical viper envenomation characterized by severe systemic coagulopathy despite minimal and non-progressive local manifestations. This unusual presentation may reflect inter- and intraspecies variation in venom composition and poses challenges for clinical recognition, management, and forensic interpretation.

Tattooing is an ancient decorative cosmetic procedure with increasing popularity, but regulations concerning professional including hygienic practice are limited. Although mild inflammatory responses due to infections, for instance, are known complications, severe sequelae are beyond consideration. Here we summarize 40 cases of invasive and systemic infections as collateral damages of decorative tattooing. Reports from 14 countries revealed that most patients were male, with a median age of 28.5 years including a 6-week-old infant. Cases were categorized into deep abscesses and cellulitis, infective endocarditis, necrotizing soft-tissue infection, toxic shock syndrome, sepsis, and others. Overall, Gram-positive bacteria including Staphylococcus aureus and streptococci dominated as infectious agents. Thirty out of 40 patients were considered immunocompetent, 23 required surgical interventions alongside antimicrobial therapy, and five cases were fatal. Severe complications occurred due to soft-tissue destruction near the tattoo, hematogenous seeding to distant sites such as the heart valves, and toxin-mediated systemic responses; unregulated inadequate hygienic practices were risk factors for such collateral damages. In conclusion, severe tattoo-associated infections are rare events but can be fatal even in immunocompetent individuals. In cases of otherwise unexplained soft-tissue, systemic, or cardiac valve infections a tattooing history should be considered even if the tattoo site looks uninflamed.

This study conducted a retrospective disproportionality analysis of 50,031 adverse drug event (ADE) reports from the FDA Adverse Event Reporting System (FAERS) database spanning Q2 2009 to Q3 2025, in which golimumab was identified as the primary suspect drug. Four disproportionality algorithms were simultaneously applied: the reporting odds ratio (ROR), proportional reporting ratio (PRR), Bayesian confidence propagation neural network (BCPNN), and multi-item gamma Poisson shrinker (MGPS). A total of 397 positive signals were identified across 25 system organ classes (SOCs). The SOCs with concordant positive signals across all four algorithms were identified for infections and infestations and surgical and medical procedures. High-frequency signals included pneumonia, lower respiratory tract infection, influenza, nasopharyngitis, sinusitis and cellulitis. Comparison with the current prescribing information revealed several previously undocumented ADEs, including urinary tract infection, ear infection, flavivirus infection, Zika virus infection and Dengue fever. Twenty-nine positive malignancy signals absent from the prescribing information were identified, including basal cell carcinoma, colorectal cancer, cervical cancer and breast cancer. Time-to-onset analysis revealed that the risk of ADEs was the highest within the first few months of treatment initiation. Clinicians should rigorously monitor for infectious complications and malignancies when prescribing golimumab to ensure patient safety.

Invasive fungal infections in cats can result in sinonasal or sino-orbital disease, with brachycephalic breeds reported to be predisposed. However, a subset of cases exhibits isolated orbital signs without clinically evident sinonasal involvement, raising questions about whether the sinonasal component is genuinely absent or subclinical at the time of presentation. This retrospective study describes 11 cats with orbital mycosis lacking overt sinonasal disease, identified through the Comparative Ocular Pathology Laboratory of Wisconsin between 1998 and 2024. All 11 cats were mesocephalic breeds (10 domestic shorthair, 1 domestic longhair), with no apparent sex predilection and ages ranging from 1.5 to 17 years (median, 7 years). All cases presented with orbital disease, most commonly exposure keratitis and exophthalmos, without documented upper respiratory signs. Histologically, lesions were characterized by eosinophilic and granulomatous orbital cellulitis with central necrosis. Aspergillus sp. were the most common organisms identified morphologically (8/11), followed by oomycetes (2/11) and Mucorales (1/11). Panfungal polymerase chain reaction confirmed Aspergillus sp. in 3 cases but frequently amplified suspected contaminants. Review of published feline orbital mycosis cases revealed that mesocephalic breeds predominantly present with orbital signs, whereas brachycephalic breeds more commonly exhibit concurrent sinonasal disease. These findings suggest that orbital mycosis in mesocephalic cats may represent subclinical sinonasal infections with preferential orbital extension, potentially reflecting anatomical differences in skull conformation.

Odontogenic infections may initially present as facial cellulitis and, when left untreated, can progress to chronic infection, abscess formation, and extraoral sinus tract development. Early diagnosis and definitive management are essential to prevent complications and recurrent infection. This case report describes an 11-year-old girl who presented to the Pediatric Dental Clinic at the Dental and Maxillofacial Center (DMFC) with recurrent swelling on the left side of the face that had been intermittently treated with antibiotics for nearly one year. Clinical examination revealed an extraoral sinus tract in the left submandibular region associated with a severely carious lower left first molar. Cone-beam computed tomography (CBCT) played an important role in establishing the odontogenic origin of the infection, demonstrating the extent of periapical pathology and buccal cortical bone destruction. Following diagnosis, definitive treatment was achieved through extraction of the affected tooth. The patient showed complete resolution of the facial swelling and extraoral sinus tract following extraction, with no further recurrence reported during follow-up. This case highlights the importance of recognizing the progression of odontogenic infection from an initial acute presentation to a chronic extraoral sinus tract in pediatric patients. It also emphasizes the diagnostic value of CBCT in complex or recurrent cases and the importance of timely definitive dental treatment rather than repeated antibiotic therapy alone.

Frontal sinus mucoceles are benign expansile lesions that may progressively erode the surrounding bone and extend toward the orbit or intracranial compartment. When expansion occurs anteriorly, however, they may present as an apparently superficial forehead swelling and be mistaken for a cutaneous abscess. A 77-year-old woman with chronic sinusitis developed recurrent left paramedian frontal swelling over several months, with only transient improvement following antibiotic treatment. The lesion was initially interpreted as a cutaneous abscess and incised in an outpatient setting. Clear, nonpurulent fluid was obtained instead of pus. Two days later, she presented with persistent frontal inflammation and newly developed left periorbital cellulitis. Despite the extent of the disease, she remained afebrile and had no headache, neurological symptoms, diplopia, or visual impairment. CT and MRI demonstrated a left frontal sinus mucocele with erosion of both the anterior and posterior frontal sinus tables, in close proximity to the superomedial orbit and dura mater. After control of the acute inflammatory process, the mucocele was treated with endoscopic endonasal marsupialization through a Draf IIc frontal sinusotomy. Complete clinical resolution was achieved, with no documented recurrence during one year of follow-up. This case illustrates an important diagnostic pitfall: the superficial appearance of a frontal swelling may conceal extensive underlying sinus disease and bony erosion. Recurrent paramedian frontal swelling, transient responses to antibiotics, clear rather than purulent drainage, or associated periorbital inflammation should prompt CT or MRI before any further incision.

This evidence-to-recommendation (EtR) framework underpins the Agency for Care Effectiveness Clinical Guideline (ACG) for bacterial skin and soft tissue infections (SSTIs), providing rationale and justifications for its recommendations on diagnosis and antibiotic prescribing in primary and community care. Based on the Grading of Recommendations Assessment, Development and Evaluation framework, five evidence-based recommendations were developed to guide practitioners in making appropriate decisions on the diagnosis, assessment and management of SSTIs, including cellulitis, erysipelas, impetigo, folliculitis, ecthyma, furuncles, carbuncles and skin abscesses. As SSTIs are a leading indication for use of oral antibiotics in primary care, recommendations focus on principles for prescribing antibiotics for specific bacterial SSTIs, including whether antibiotics are indicated and when to prescribe topical, oral or intravenous formulations. The EtR framework consolidates the evidence and considerations that informed the ACG recommendations, including balance of benefits and risks, certainty of evidence, patient preferences and values, resources and feasibility considerations, and acceptability. The ACG can be found at https://go.gov.sg/acg-ssti.

Myiasis is a parasitic infestation caused by dipterous larvae and is an important diagnostic consideration in travellers returning from endemic regions with infected skin lesions. Paediatric cases present unique management challenges, particularly when invasive procedures or general anaesthesia are considered. We report a case of cutaneous myiasis with associated cellulitis in a toddler following travel to Gambia, caused by Cordylobia anthropophaga (tumbu fly). A novel non-operative approach using eutectic mixture of local anaesthetic cream was successfully employed to facilitate larval extraction, avoiding the need for surgical intervention. This case highlights a safe, effective and minimally invasive technique for managing paediatric cutaneous myiasis in an emergency department setting.