Ndidi Unaka, MD, MEd

This icon represents the patient’s case. Each paragraph that follows represents the discussant’s thoughts.

A 32-year-old, previously healthy woman presented to the emergency department (ED) with 3 days of nasal pain, congestion, and cough. A day prior, she had consulted with her primary care provider by phone and had been prescribed amoxicillin-clavulanate for presumed bacterial sinusitis. She subsequently developed fever (39 oC) and pleuritic, left-upper-quadrant abdominal pain. In the ED, chest radiograph demonstrated right hilar opacification. Laboratory studies and computed tomography (CT) of the abdomen and pelvis did not identify a cause for her pain. Given the pleuritic nature of her left-upper-quadrant pain, CT pulmonary angiography was ordered. The CT revealed “mass-like” right hilar opacification and lymphadenopathy. No pulmonary emboli were identified. Levofloxacin was prescribed for presumed pneumonia, and the patient was discharged home. The following week, mediastinal biopsy was arranged for evaluation of the right hilar abnormality.

This is a young woman presenting with upper respiratory symptoms, abdominal pain, fever, and hilar lymphadenopathy. Upper respiratory symptoms are common and usually indicate an inflammatory response to allergens or infection, though autoimmune disorders may affect the upper airways. Fever and hilar lymphadenopathy likely also signify an inflammatory response. Taken together, these findings can be associated with mycobacterial or fungal infection, malignancy, and, particularly in a young woman, sarcoidosis, which could explain her abdominal pain if her presentation included splenomegaly. At this point she likely has a systemic illness involving at least the upper, and possibly the lower, respiratory tract.

Within days, her symptoms resolved. Mediastinal biopsy of the hilar node revealed scant pus. Pathology demonstrated suppurative granulomata. Gram stain; bacterial, mycobacterial, and fungal cultures; and 16S ribosomal analyses for bacteria and fungi from the biopsy were unrevealing. For unclear reasons, prior to the biopsy, she was given intramuscular Haemophilus influenzae type B and tetanus, diphtheria, and pertussis vaccines. Two weeks later, she presented again with fever and left-upper-quadrant pain as well as painful skin nodules at her biopsy and vaccination sites. She was admitted for further evaluation. Chest CT showed expansion of the mediastinal lesion and splenic enlargement. Biopsy of a skin lesion revealed suppurative granulomatous dermatitis and panniculitis. Repeat blood cultures were negative, though serum β-D-glucan was weakly positive at 173 pg/mL (reference range, <60 pg/mL). Tissue cultures and Gram, acid-fast, Fite, and Warthin-Starry stains from the skin biopsy were negative. She was discharged on fluconazole and then readmitted 2 days later with dyspnea, fever, and leukocytosis.

The young woman’s symptoms resolved, only to recur days later; her granulomatous hilar lesions grew larger, and new cutaneous and splenic findings appeared. The granulomatous lesions prompt consideration of infectious, malignant, and immune-mediated processes. The negative cultures make infection less likely, although the elevated β-D-glucan may suggest fungal infection. By description, the skin lesions are consistent with pathergy, a phenomenon characterized by trauma-provoked cutaneous lesions or ulcers, which is associated with numerous syndromes, including Behçet syndrome, inflammatory bowel disease, and neutrophilic dermatoses such as pyoderma gangrenosum (PG) and Sweet syndrome. In addition to details about her medical history, it is important to seek evidence of oral ulcers or vasculitis, as Behçet syndrome may be associated with cutaneous, visceral, and ophthalmologic vasculitis.

Her medical history included hypertension and active, 10-pack-year cigarette use. During childhood, she had occasional ingrown hairs and folliculitis. She did not take medications prior to this acute illness. Family history was notable for cardiovascular disease. She rarely consumed alcohol and did not use illicit drugs. She lived in a rural town in the mid–Willamette Valley of Oregon and worked as an administrative assistant. She spent time outdoors, including trail running and golfing. A case of tularemia was recently reported in an area near her home. Her only travel outside of Oregon was to Puerto Vallarta, Mexico, 16 years previously. She grew up on a farm and had no known tuberculosis exposure.

Tularemia is an interesting diagnostic consideration and could explain her fever, cutaneous lesions, and hilar adenopathy. It is plausible that she had clinically mild pneumonic tularemia at the outset and that her cutaneous lesions are variants of ulceroglandular tularemia. Positive antibodies for Francisella tularensis would be expected if this were the cause of her illness. The ingrown hairs raise the possibility of a primary immune deficiency syndrome predisposing her to abscesses. However, they seem to have been of trivial significance to her, making an immune deficiency syndrome unlikely.

On readmission, she was afebrile, normotensive, and tachycardic (114 beats/min), with a normal respiratory rate and oxygen saturation. She was not ill appearing. She had noninjected conjunctiva and no oral lesions. Apart from tachycardia, cardiovascular examination was unremarkable. Abdominal examination was notable for mild distension and a palpable, tender spleen. Musculoskeletal and neurologic examinations were normal. Her skin was notable for various sized (8 cm × 4 cm to 10 cm × 15 cm) painful ulcers with violaceous, friable borders—some with fluctuance and purulent drainage—on her right hand, bilateral arms, right axilla, sternum, and legs (Figure 1).

JHMVol16No9_Burnett14940915e_f1.JPG

Laboratory studies were notable for normocytic anemia (hemoglobin, 8.9 g/dL; range, 12.0-16.0 g/dL), leukocytosis (white blood cells, 24,900/µL; range, 4500-11,000/µL), thrombocytosis (platelet count, 690,000/µL; range, 150,000-400,000/µL), and elevated inflammatory markers (C-reactive protein, 33 mg/dL; range, <0.5 mg/dL; erythrocyte sedimentation rate, 78 mm/h; range, <20 mm/h). A complete metabolic panel was within normal limits. Repeat blood cultures and β -D-glucan and 16S ribosomal assays were negative. Polymerase chain reaction testing for Bartonella henselae was negative. Urine probes for Neisseria gonorrhoeae and Chlamydia trachomatis were negative. Rapid plasma regain (RPR) was negative. Antibodies to toxoplasmosis, histoplasmosis, blastomycosis, and aspergillosis were unrevealing. A Coccidioides test by immunodiffusion was negative. Serum antigen tests for Cryptococcus and Epstein-Barr virus (EBV) were negative. EBV, HIV, and hepatitis antibody tests were negative. Rheumatologic studies, including antinuclear, anti-double-stranded DNA, anti-Smith, anti–Sjögren syndrome antigens A and B, anticentromere, anti-topoisomerase (anti-Scl-70), anti-histidyl-transfer-RNA-synthetase (anti-Jo-1), and anti-nucleosome (anti-chromatic) antibodies, were unrevealing. Levels of angiotensin-converting enzyme, rheumatoid factor, complement, cytoplasmic, and perinuclear antineutrophil cytoplasmic antibodies were also normal. A neutrophil oxidative burst test was negative. In addition, peripheral flow cytology and serum and urine protein electrophoresis were negative. Chest CT revealed bilateral lower lobe consolidations concerning for necrotizing pneumonia, splenic enlargement, numerous hypodense splenic lesions, and a 1.3-cm right hilar node, which had decreased in size compared with 1 month prior.

In summary, the patient presented with recurrent upper respiratory symptoms, fever, and abdominal pain; expanding granulomatous hilar lesions, splenomegaly, and cutaneous lesions consistent with pathergy; elevated inflammatory markers and leukocytosis; and a possible exposure to F tularensis. She has had extensive negative infectious workups, except for a weakly positive β-D-glucan, and completed several courses of apparently unhelpful antimicrobials. At this point, the most notable findings are her splenomegaly and inflammatory masses suggesting an inflammatory process, which may be autoimmune in nature. Both vasculitis and sarcoidosis remain possibilities, and malignancy is possible. Given her possible exposure to F tularensis, obtaining serum antibodies to F tularensis, in addition to biopsies of the skin lesions, is advisable.

Laboratory studies revealed a positive F tularensis antibody with a titer of 1:320 and an IgM of 7 U/mL and IgG of 30 U/mL. This was repeated, revealing a titer of 1:540 and an IgM and IgG of 5 U/mL and 20 U/mL, respectively. Given the potential exposure history, the clinical syndrome compatible with tularemia, and an otherwise extensive yet unrevealing evaluation, she was treated with a 10-day course of streptomycin. Her fever persisted, and the splenic lesions increased in size and number, prompting addition of moxifloxacin without apparent benefit. Skin biopsies taken from the patient’s arm were notable for nodular, suppurative, neutrophilic infiltrates and histiocytes in the medium and deep dermis without multinucleated histiocytes or evidence of vasculitis. Fungal, mycobacterial, and bacterial stains from the biopsy were negative. The findings were consistent with but not diagnostic of an acute neutrophilic dermatosis.

At this point, the patient has a confirmed exposure to F tularensis; she also has persistent fever, progressive splenomegaly, and new skin biopsies consistent with neutrophilic dermatosis. Despite the F tularensis antibody positivity, her negative cultures and lack of improvement with multiple courses of antimicrobials argue against an infectious etiology. Accordingly, malignancy should be considered but seems less likely given that no laboratory, imaging, or tissue samples support it. This leaves immune-mediated etiologies, especially autoimmune conditions associated with neutrophilic dermatoses, as the most likely explanation of her inflammatory syndrome. Neutrophilic dermatoses include some vasculitides, Sweet syndrome, PG, Behçet syndrome, and other inflammatory entities. She has no evidence of vasculitis on biopsy. Given the evidence of inflammation and the history of pathergy, Behçet syndrome and PG should be seriously considered.

She underwent incision and drainage of the left leg and mediastinal lesions. A follow-up chest CT revealed stable cutaneous and deep tissue lesions and continued splenic enlargement. She was started on prednisone and dapsone for presumed cutaneous and visceral PG. The lesions improved dramatically and, following a month-long hospitalization, she was discharged on dapsone and a slow prednisone taper. Three weeks after discharge, while on dapsone and prednisone, she developed a new skin lesion. Cyclosporine was added, with improvement. Eight weeks after discharge, she developed fever, acute left-upper-quadrant pain, and marked splenomegaly with abscesses seen on CT imaging (Figure 2).

JHMVol16No9_Burnett14940915e_f2.JPG

This continues to be a very puzzling case, and it is worth revisiting her clinical course once again. This is a previously healthy 32-year-old woman with multiple hospital presentations for upper-respiratory symptoms, persistent fever, abdominal pain, and painful cutaneous lesions consistent with pathergy; she was found to have granulomatous hilar lesions, progressive splenomegaly, and skin biopsies consistent with neutrophilic dermatosis. Exhaustive infectious and rheumatologic workup was negative, and no evident malignancy was found. Finally, despite multiple courses of antimicrobials, including standard treatments for tularemia (for which she had positive antibodies), her clinical course failed to improve until the addition of systemic anti-inflammatory agents, which resulted in rapid improvement. She then presented 8 weeks later with recurrent fever and splenomegaly. Given the recurrence and the severity of the splenic pathology, a diagnostic splenectomy is advisable for what appears to be visceral PG. In addition, attempting to identify a trigger of her syndrome is important. PG can be associated with inflammatory bowel disease, hematologic disorders (eg, leukemia, myeloma, myelodysplastic syndrome, and myelofibrosis), and autoimmune diseases, especially inflammatory arthritis.¹ Therefore, a diagnostic colonoscopy and bone marrow biopsy should be considered. With no history or examination supporting inflammatory arthritis and a broad, unrevealing workup, her rheumatologic evaluation is sufficient.

The patient underwent splenectomy. Gross description of the spleen was notable for multiple abscesses, consisting on microscopy of large areas of necrosis with islands of dense neutrophil collections (Figure 3). Microscopic examination failed to demonstrate microorganisms on multiple stains, and there was no microscopic or flow cytometric evidence of lymphoma. The final pathologic diagnosis was multiple sterile splenic abscesses with siderosis, which, in the context of her overall syndrome, was consistent with an entity termed aseptic abscess syndrome (AAS). After discharge, she underwent a slow steroid taper and was ultimately maintained on daily low-dose prednisone. Cyclosporine and dapsone were discontinued in favor of infliximab infusions. She underwent additional diagnostic workup, including an unremarkable colonoscopy and a bone marrow biopsy, which showed monoclonal gammopathy of undetermined significance (MGUS) with an insignificant IgA monoclonal gammopathy. All cutaneous lesions healed. Three years after the splenectomy, while still on infliximab and prednisone, she developed a new aseptic lung abscess, which resolved after increasing her prednisone dose. Six years after splenectomy, she developed an aseptic liver abscess, which resolved after again increasing the frequency of her infliximab infusions.

JHMVol16No9_Burnett14940915e_f3.JPG

Diagnostic uncertainty is an intrinsic feature of medical practice—in part because patients often present with undifferentiated and evolving symptoms.² When faced with uncertainty, clinicians are well served by prioritizing a thoughtful differential diagnosis, adopting a stepwise management strategy, and engaging in iterative reassessments of the patient. In this case, a 32-year-old, previously healthy woman presented with an array of symptoms, including abdominal pain, fever, leukocytosis, necrotic skin lesions, necrotizing mediastinal lymphadenitis, pathergy, and splenomegaly. Elements of the history, examination, and diagnostic studies supported a differential diagnosis of tularemia, PG, and AAS. Through stepwise management and ongoing reassessment, she was ultimately diagnosed with AAS.

Tularemia was initially an important diagnostic consideration in this patient, given her potential exposure and positive F tularensis serum antibodies. Francisella tularensis is a Gram-negative coccobacillus found in more than 250 species of fish, ticks, birds, and mammals. In humans, an incubation period of 3 to 5 days is typical. Although clinical manifestations vary, they often include fever, headache, and malaise.³ Other findings may include lymphadenopathy with or without ulcerative cutaneous lesions (glandular or ulceroglandular tularemia) and cough, dyspnea, pleuritic chest pain, and hilar adenopathy (pneumonic tularemia). As noted by the discussant, a pneumonic tularemia syndrome could have explained this patient’s fever, respiratory symptoms, and hilar adenopathy; ulceroglandular tularemia might have explained her cutaneous lesions. Since splenomegaly may be seen in tularemia, this finding was also consistent with the diagnosis. Serum antibody testing is supportive of the diagnosis, while culture confirms it. Standard treatment consists of a 10- to 14-day course of streptomycin, and combination therapy with a fluoroquinolone is recommended in severe cases.⁴ In this patient, however, F tularensis was not demonstrated on culture. Furthermore, she did not experience the expected clinical improvement with treatment. Finally, because both IgG and IgM tularemia antibodies may co-occur up to 10 years following infection, her positive F tularensis serum antibodies did not provide evidence of acute infection.⁵

Recognizing inconsistencies in the diagnosis of tularemia, the focus shifted to PG owing to the patient’s neutrophilic cutaneous lesions, negative infectious workup, and pathergy. Pyoderma gangrenosum is a neutrophilic dermatosis—one of a heterogeneous group of skin conditions characterized by perivascular and diffuse neutrophilic infiltrates without an identifiable infectious agent.⁶ It is a chronic, recurrent cutaneous disease with several variants.⁷ The classic presentation includes painful lower-extremity ulcers with violaceous undermined borders and may be associated with pathergy. Guiding principles for the management of PG include controlling inflammation, optimizing wound healing, and minimizing exacerbating factors.¹ As such, treatment mainstays include local and systemic anti-inflammatory agents and wound care. As the discussant highlighted, in this case the inflammatory skin lesions were suggestive of PG. However, other features of the case, notably, splenomegaly, splenic abscesses, and necrotizing mediastinal lymphadenitis, were more consistent with another diagnosis: AAS. Aseptic abscess syndrome is an autoinflammatory disorder defined by deep, noninfectious abscesses that preferentially affect the spleen.⁸ Additional clinical manifestations include weight loss, fever, abdominal pain, and leukocytosis. Lesions may also affect bone, kidney, liver, lung, lymph node, and skin. In one case series, neutrophilic dermatoses were seen in 20% of AAS cases.⁸ In all cases of AAS, extensive infectious workup is unrevealing, and antibiotics are ineffective. The pathophysiology of AAS is unknown.

Similar to PG, the majority of AAS cases are associated with inflammatory bowel disease, especially Crohn disease.⁹ However, AAS also has associations with conditions such as MGUS, rheumatoid arthritis, spondyloarthritis, and relapsing polychondritis. Histologically, early lesions demonstrate a necrotic core of neutrophils, with or without surrounding palisading histiocytes, and giant cells. In older lesions, neutrophils may be absent; fibrous tissue may be present.⁸ Treatment regimens include splenectomy, corticosteroids, colchicine, thalidomide, tumor necrosis factor (TNF) antagonists, and cyclophosphamide. The discussant astutely recommended a splenectomy for this patient, which was both diagnostic and therapeutic. As in this case, relapse is common. Optimal maintenance therapy is yet to be determined.⁹

Given the overlapping clinical manifestations, shared disease associations, and similar responsiveness to immunosuppression, it is unclear whether AAS represents a new disease entity or a variant of known autoinflammatory disorders. Aseptic abscess syndrome is likely part of a spectrum of autoinflammatory disorders with inflammatory bowel diseases, neutrophilic dermatoses, and other similar diseases.⁸ While infectious visceral abscesses remain more common, this case highlights the clinical manifestation of an emerging and likely underrecognized entity.

• Aseptic abscess syndrome should be considered in patients who present with visceral (particularly splenic) abscesses and negative infectious workup.
• Aseptic abscess syndrome is commonly associated with other autoinflammatory disorders; the majority of reported cases are associated with inflammatory bowel disease, especially Crohn disease.
• Up to 20% of AAS cases are associated with neutrophilic dermatoses such as PG.
• The initial treatment for this syndrome is high-dose intravenous glucocorticoids; maintenance treatment regimens include corticosteroids, colchicine, thalidomide, TNF antagonists, and cyclophosphamide.

The authors would thank Dr Bob Pelz and Dr John Townes for their contributions to the case.

This icon represents the patient’s case. Each paragraph that follows represents the discussant’s thoughts.

A 32-year-old, previously healthy woman presented to the emergency department (ED) with 3 days of nasal pain, congestion, and cough. A day prior, she had consulted with her primary care provider by phone and had been prescribed amoxicillin-clavulanate for presumed bacterial sinusitis. She subsequently developed fever (39 oC) and pleuritic, left-upper-quadrant abdominal pain. In the ED, chest radiograph demonstrated right hilar opacification. Laboratory studies and computed tomography (CT) of the abdomen and pelvis did not identify a cause for her pain. Given the pleuritic nature of her left-upper-quadrant pain, CT pulmonary angiography was ordered. The CT revealed “mass-like” right hilar opacification and lymphadenopathy. No pulmonary emboli were identified. Levofloxacin was prescribed for presumed pneumonia, and the patient was discharged home. The following week, mediastinal biopsy was arranged for evaluation of the right hilar abnormality.

This is a young woman presenting with upper respiratory symptoms, abdominal pain, fever, and hilar lymphadenopathy. Upper respiratory symptoms are common and usually indicate an inflammatory response to allergens or infection, though autoimmune disorders may affect the upper airways. Fever and hilar lymphadenopathy likely also signify an inflammatory response. Taken together, these findings can be associated with mycobacterial or fungal infection, malignancy, and, particularly in a young woman, sarcoidosis, which could explain her abdominal pain if her presentation included splenomegaly. At this point she likely has a systemic illness involving at least the upper, and possibly the lower, respiratory tract.

Within days, her symptoms resolved. Mediastinal biopsy of the hilar node revealed scant pus. Pathology demonstrated suppurative granulomata. Gram stain; bacterial, mycobacterial, and fungal cultures; and 16S ribosomal analyses for bacteria and fungi from the biopsy were unrevealing. For unclear reasons, prior to the biopsy, she was given intramuscular Haemophilus influenzae type B and tetanus, diphtheria, and pertussis vaccines. Two weeks later, she presented again with fever and left-upper-quadrant pain as well as painful skin nodules at her biopsy and vaccination sites. She was admitted for further evaluation. Chest CT showed expansion of the mediastinal lesion and splenic enlargement. Biopsy of a skin lesion revealed suppurative granulomatous dermatitis and panniculitis. Repeat blood cultures were negative, though serum β-D-glucan was weakly positive at 173 pg/mL (reference range, <60 pg/mL). Tissue cultures and Gram, acid-fast, Fite, and Warthin-Starry stains from the skin biopsy were negative. She was discharged on fluconazole and then readmitted 2 days later with dyspnea, fever, and leukocytosis.

The young woman’s symptoms resolved, only to recur days later; her granulomatous hilar lesions grew larger, and new cutaneous and splenic findings appeared. The granulomatous lesions prompt consideration of infectious, malignant, and immune-mediated processes. The negative cultures make infection less likely, although the elevated β-D-glucan may suggest fungal infection. By description, the skin lesions are consistent with pathergy, a phenomenon characterized by trauma-provoked cutaneous lesions or ulcers, which is associated with numerous syndromes, including Behçet syndrome, inflammatory bowel disease, and neutrophilic dermatoses such as pyoderma gangrenosum (PG) and Sweet syndrome. In addition to details about her medical history, it is important to seek evidence of oral ulcers or vasculitis, as Behçet syndrome may be associated with cutaneous, visceral, and ophthalmologic vasculitis.

Her medical history included hypertension and active, 10-pack-year cigarette use. During childhood, she had occasional ingrown hairs and folliculitis. She did not take medications prior to this acute illness. Family history was notable for cardiovascular disease. She rarely consumed alcohol and did not use illicit drugs. She lived in a rural town in the mid–Willamette Valley of Oregon and worked as an administrative assistant. She spent time outdoors, including trail running and golfing. A case of tularemia was recently reported in an area near her home. Her only travel outside of Oregon was to Puerto Vallarta, Mexico, 16 years previously. She grew up on a farm and had no known tuberculosis exposure.

Tularemia is an interesting diagnostic consideration and could explain her fever, cutaneous lesions, and hilar adenopathy. It is plausible that she had clinically mild pneumonic tularemia at the outset and that her cutaneous lesions are variants of ulceroglandular tularemia. Positive antibodies for Francisella tularensis would be expected if this were the cause of her illness. The ingrown hairs raise the possibility of a primary immune deficiency syndrome predisposing her to abscesses. However, they seem to have been of trivial significance to her, making an immune deficiency syndrome unlikely.

On readmission, she was afebrile, normotensive, and tachycardic (114 beats/min), with a normal respiratory rate and oxygen saturation. She was not ill appearing. She had noninjected conjunctiva and no oral lesions. Apart from tachycardia, cardiovascular examination was unremarkable. Abdominal examination was notable for mild distension and a palpable, tender spleen. Musculoskeletal and neurologic examinations were normal. Her skin was notable for various sized (8 cm × 4 cm to 10 cm × 15 cm) painful ulcers with violaceous, friable borders—some with fluctuance and purulent drainage—on her right hand, bilateral arms, right axilla, sternum, and legs (Figure 1).

JHMVol16No9_Burnett14940915e_f1.JPG

Laboratory studies were notable for normocytic anemia (hemoglobin, 8.9 g/dL; range, 12.0-16.0 g/dL), leukocytosis (white blood cells, 24,900/µL; range, 4500-11,000/µL), thrombocytosis (platelet count, 690,000/µL; range, 150,000-400,000/µL), and elevated inflammatory markers (C-reactive protein, 33 mg/dL; range, <0.5 mg/dL; erythrocyte sedimentation rate, 78 mm/h; range, <20 mm/h). A complete metabolic panel was within normal limits. Repeat blood cultures and β -D-glucan and 16S ribosomal assays were negative. Polymerase chain reaction testing for Bartonella henselae was negative. Urine probes for Neisseria gonorrhoeae and Chlamydia trachomatis were negative. Rapid plasma regain (RPR) was negative. Antibodies to toxoplasmosis, histoplasmosis, blastomycosis, and aspergillosis were unrevealing. A Coccidioides test by immunodiffusion was negative. Serum antigen tests for Cryptococcus and Epstein-Barr virus (EBV) were negative. EBV, HIV, and hepatitis antibody tests were negative. Rheumatologic studies, including antinuclear, anti-double-stranded DNA, anti-Smith, anti–Sjögren syndrome antigens A and B, anticentromere, anti-topoisomerase (anti-Scl-70), anti-histidyl-transfer-RNA-synthetase (anti-Jo-1), and anti-nucleosome (anti-chromatic) antibodies, were unrevealing. Levels of angiotensin-converting enzyme, rheumatoid factor, complement, cytoplasmic, and perinuclear antineutrophil cytoplasmic antibodies were also normal. A neutrophil oxidative burst test was negative. In addition, peripheral flow cytology and serum and urine protein electrophoresis were negative. Chest CT revealed bilateral lower lobe consolidations concerning for necrotizing pneumonia, splenic enlargement, numerous hypodense splenic lesions, and a 1.3-cm right hilar node, which had decreased in size compared with 1 month prior.

In summary, the patient presented with recurrent upper respiratory symptoms, fever, and abdominal pain; expanding granulomatous hilar lesions, splenomegaly, and cutaneous lesions consistent with pathergy; elevated inflammatory markers and leukocytosis; and a possible exposure to F tularensis. She has had extensive negative infectious workups, except for a weakly positive β-D-glucan, and completed several courses of apparently unhelpful antimicrobials. At this point, the most notable findings are her splenomegaly and inflammatory masses suggesting an inflammatory process, which may be autoimmune in nature. Both vasculitis and sarcoidosis remain possibilities, and malignancy is possible. Given her possible exposure to F tularensis, obtaining serum antibodies to F tularensis, in addition to biopsies of the skin lesions, is advisable.

Laboratory studies revealed a positive F tularensis antibody with a titer of 1:320 and an IgM of 7 U/mL and IgG of 30 U/mL. This was repeated, revealing a titer of 1:540 and an IgM and IgG of 5 U/mL and 20 U/mL, respectively. Given the potential exposure history, the clinical syndrome compatible with tularemia, and an otherwise extensive yet unrevealing evaluation, she was treated with a 10-day course of streptomycin. Her fever persisted, and the splenic lesions increased in size and number, prompting addition of moxifloxacin without apparent benefit. Skin biopsies taken from the patient’s arm were notable for nodular, suppurative, neutrophilic infiltrates and histiocytes in the medium and deep dermis without multinucleated histiocytes or evidence of vasculitis. Fungal, mycobacterial, and bacterial stains from the biopsy were negative. The findings were consistent with but not diagnostic of an acute neutrophilic dermatosis.

At this point, the patient has a confirmed exposure to F tularensis; she also has persistent fever, progressive splenomegaly, and new skin biopsies consistent with neutrophilic dermatosis. Despite the F tularensis antibody positivity, her negative cultures and lack of improvement with multiple courses of antimicrobials argue against an infectious etiology. Accordingly, malignancy should be considered but seems less likely given that no laboratory, imaging, or tissue samples support it. This leaves immune-mediated etiologies, especially autoimmune conditions associated with neutrophilic dermatoses, as the most likely explanation of her inflammatory syndrome. Neutrophilic dermatoses include some vasculitides, Sweet syndrome, PG, Behçet syndrome, and other inflammatory entities. She has no evidence of vasculitis on biopsy. Given the evidence of inflammation and the history of pathergy, Behçet syndrome and PG should be seriously considered.

She underwent incision and drainage of the left leg and mediastinal lesions. A follow-up chest CT revealed stable cutaneous and deep tissue lesions and continued splenic enlargement. She was started on prednisone and dapsone for presumed cutaneous and visceral PG. The lesions improved dramatically and, following a month-long hospitalization, she was discharged on dapsone and a slow prednisone taper. Three weeks after discharge, while on dapsone and prednisone, she developed a new skin lesion. Cyclosporine was added, with improvement. Eight weeks after discharge, she developed fever, acute left-upper-quadrant pain, and marked splenomegaly with abscesses seen on CT imaging (Figure 2).

JHMVol16No9_Burnett14940915e_f2.JPG

This continues to be a very puzzling case, and it is worth revisiting her clinical course once again. This is a previously healthy 32-year-old woman with multiple hospital presentations for upper-respiratory symptoms, persistent fever, abdominal pain, and painful cutaneous lesions consistent with pathergy; she was found to have granulomatous hilar lesions, progressive splenomegaly, and skin biopsies consistent with neutrophilic dermatosis. Exhaustive infectious and rheumatologic workup was negative, and no evident malignancy was found. Finally, despite multiple courses of antimicrobials, including standard treatments for tularemia (for which she had positive antibodies), her clinical course failed to improve until the addition of systemic anti-inflammatory agents, which resulted in rapid improvement. She then presented 8 weeks later with recurrent fever and splenomegaly. Given the recurrence and the severity of the splenic pathology, a diagnostic splenectomy is advisable for what appears to be visceral PG. In addition, attempting to identify a trigger of her syndrome is important. PG can be associated with inflammatory bowel disease, hematologic disorders (eg, leukemia, myeloma, myelodysplastic syndrome, and myelofibrosis), and autoimmune diseases, especially inflammatory arthritis.¹ Therefore, a diagnostic colonoscopy and bone marrow biopsy should be considered. With no history or examination supporting inflammatory arthritis and a broad, unrevealing workup, her rheumatologic evaluation is sufficient.

The patient underwent splenectomy. Gross description of the spleen was notable for multiple abscesses, consisting on microscopy of large areas of necrosis with islands of dense neutrophil collections (Figure 3). Microscopic examination failed to demonstrate microorganisms on multiple stains, and there was no microscopic or flow cytometric evidence of lymphoma. The final pathologic diagnosis was multiple sterile splenic abscesses with siderosis, which, in the context of her overall syndrome, was consistent with an entity termed aseptic abscess syndrome (AAS). After discharge, she underwent a slow steroid taper and was ultimately maintained on daily low-dose prednisone. Cyclosporine and dapsone were discontinued in favor of infliximab infusions. She underwent additional diagnostic workup, including an unremarkable colonoscopy and a bone marrow biopsy, which showed monoclonal gammopathy of undetermined significance (MGUS) with an insignificant IgA monoclonal gammopathy. All cutaneous lesions healed. Three years after the splenectomy, while still on infliximab and prednisone, she developed a new aseptic lung abscess, which resolved after increasing her prednisone dose. Six years after splenectomy, she developed an aseptic liver abscess, which resolved after again increasing the frequency of her infliximab infusions.

JHMVol16No9_Burnett14940915e_f3.JPG

Diagnostic uncertainty is an intrinsic feature of medical practice—in part because patients often present with undifferentiated and evolving symptoms.² When faced with uncertainty, clinicians are well served by prioritizing a thoughtful differential diagnosis, adopting a stepwise management strategy, and engaging in iterative reassessments of the patient. In this case, a 32-year-old, previously healthy woman presented with an array of symptoms, including abdominal pain, fever, leukocytosis, necrotic skin lesions, necrotizing mediastinal lymphadenitis, pathergy, and splenomegaly. Elements of the history, examination, and diagnostic studies supported a differential diagnosis of tularemia, PG, and AAS. Through stepwise management and ongoing reassessment, she was ultimately diagnosed with AAS.

Tularemia was initially an important diagnostic consideration in this patient, given her potential exposure and positive F tularensis serum antibodies. Francisella tularensis is a Gram-negative coccobacillus found in more than 250 species of fish, ticks, birds, and mammals. In humans, an incubation period of 3 to 5 days is typical. Although clinical manifestations vary, they often include fever, headache, and malaise.³ Other findings may include lymphadenopathy with or without ulcerative cutaneous lesions (glandular or ulceroglandular tularemia) and cough, dyspnea, pleuritic chest pain, and hilar adenopathy (pneumonic tularemia). As noted by the discussant, a pneumonic tularemia syndrome could have explained this patient’s fever, respiratory symptoms, and hilar adenopathy; ulceroglandular tularemia might have explained her cutaneous lesions. Since splenomegaly may be seen in tularemia, this finding was also consistent with the diagnosis. Serum antibody testing is supportive of the diagnosis, while culture confirms it. Standard treatment consists of a 10- to 14-day course of streptomycin, and combination therapy with a fluoroquinolone is recommended in severe cases.⁴ In this patient, however, F tularensis was not demonstrated on culture. Furthermore, she did not experience the expected clinical improvement with treatment. Finally, because both IgG and IgM tularemia antibodies may co-occur up to 10 years following infection, her positive F tularensis serum antibodies did not provide evidence of acute infection.⁵

Recognizing inconsistencies in the diagnosis of tularemia, the focus shifted to PG owing to the patient’s neutrophilic cutaneous lesions, negative infectious workup, and pathergy. Pyoderma gangrenosum is a neutrophilic dermatosis—one of a heterogeneous group of skin conditions characterized by perivascular and diffuse neutrophilic infiltrates without an identifiable infectious agent.⁶ It is a chronic, recurrent cutaneous disease with several variants.⁷ The classic presentation includes painful lower-extremity ulcers with violaceous undermined borders and may be associated with pathergy. Guiding principles for the management of PG include controlling inflammation, optimizing wound healing, and minimizing exacerbating factors.¹ As such, treatment mainstays include local and systemic anti-inflammatory agents and wound care. As the discussant highlighted, in this case the inflammatory skin lesions were suggestive of PG. However, other features of the case, notably, splenomegaly, splenic abscesses, and necrotizing mediastinal lymphadenitis, were more consistent with another diagnosis: AAS. Aseptic abscess syndrome is an autoinflammatory disorder defined by deep, noninfectious abscesses that preferentially affect the spleen.⁸ Additional clinical manifestations include weight loss, fever, abdominal pain, and leukocytosis. Lesions may also affect bone, kidney, liver, lung, lymph node, and skin. In one case series, neutrophilic dermatoses were seen in 20% of AAS cases.⁸ In all cases of AAS, extensive infectious workup is unrevealing, and antibiotics are ineffective. The pathophysiology of AAS is unknown.

Similar to PG, the majority of AAS cases are associated with inflammatory bowel disease, especially Crohn disease.⁹ However, AAS also has associations with conditions such as MGUS, rheumatoid arthritis, spondyloarthritis, and relapsing polychondritis. Histologically, early lesions demonstrate a necrotic core of neutrophils, with or without surrounding palisading histiocytes, and giant cells. In older lesions, neutrophils may be absent; fibrous tissue may be present.⁸ Treatment regimens include splenectomy, corticosteroids, colchicine, thalidomide, tumor necrosis factor (TNF) antagonists, and cyclophosphamide. The discussant astutely recommended a splenectomy for this patient, which was both diagnostic and therapeutic. As in this case, relapse is common. Optimal maintenance therapy is yet to be determined.⁹

Given the overlapping clinical manifestations, shared disease associations, and similar responsiveness to immunosuppression, it is unclear whether AAS represents a new disease entity or a variant of known autoinflammatory disorders. Aseptic abscess syndrome is likely part of a spectrum of autoinflammatory disorders with inflammatory bowel diseases, neutrophilic dermatoses, and other similar diseases.⁸ While infectious visceral abscesses remain more common, this case highlights the clinical manifestation of an emerging and likely underrecognized entity.

• Aseptic abscess syndrome should be considered in patients who present with visceral (particularly splenic) abscesses and negative infectious workup.
• Aseptic abscess syndrome is commonly associated with other autoinflammatory disorders; the majority of reported cases are associated with inflammatory bowel disease, especially Crohn disease.
• Up to 20% of AAS cases are associated with neutrophilic dermatoses such as PG.
• The initial treatment for this syndrome is high-dose intravenous glucocorticoids; maintenance treatment regimens include corticosteroids, colchicine, thalidomide, TNF antagonists, and cyclophosphamide.

The authors would thank Dr Bob Pelz and Dr John Townes for their contributions to the case.

This icon represents the patient’s case. Each paragraph that follows represents the discussant’s thoughts.

A 32-year-old, previously healthy woman presented to the emergency department (ED) with 3 days of nasal pain, congestion, and cough. A day prior, she had consulted with her primary care provider by phone and had been prescribed amoxicillin-clavulanate for presumed bacterial sinusitis. She subsequently developed fever (39 oC) and pleuritic, left-upper-quadrant abdominal pain. In the ED, chest radiograph demonstrated right hilar opacification. Laboratory studies and computed tomography (CT) of the abdomen and pelvis did not identify a cause for her pain. Given the pleuritic nature of her left-upper-quadrant pain, CT pulmonary angiography was ordered. The CT revealed “mass-like” right hilar opacification and lymphadenopathy. No pulmonary emboli were identified. Levofloxacin was prescribed for presumed pneumonia, and the patient was discharged home. The following week, mediastinal biopsy was arranged for evaluation of the right hilar abnormality.

This is a young woman presenting with upper respiratory symptoms, abdominal pain, fever, and hilar lymphadenopathy. Upper respiratory symptoms are common and usually indicate an inflammatory response to allergens or infection, though autoimmune disorders may affect the upper airways. Fever and hilar lymphadenopathy likely also signify an inflammatory response. Taken together, these findings can be associated with mycobacterial or fungal infection, malignancy, and, particularly in a young woman, sarcoidosis, which could explain her abdominal pain if her presentation included splenomegaly. At this point she likely has a systemic illness involving at least the upper, and possibly the lower, respiratory tract.

Within days, her symptoms resolved. Mediastinal biopsy of the hilar node revealed scant pus. Pathology demonstrated suppurative granulomata. Gram stain; bacterial, mycobacterial, and fungal cultures; and 16S ribosomal analyses for bacteria and fungi from the biopsy were unrevealing. For unclear reasons, prior to the biopsy, she was given intramuscular Haemophilus influenzae type B and tetanus, diphtheria, and pertussis vaccines. Two weeks later, she presented again with fever and left-upper-quadrant pain as well as painful skin nodules at her biopsy and vaccination sites. She was admitted for further evaluation. Chest CT showed expansion of the mediastinal lesion and splenic enlargement. Biopsy of a skin lesion revealed suppurative granulomatous dermatitis and panniculitis. Repeat blood cultures were negative, though serum β-D-glucan was weakly positive at 173 pg/mL (reference range, <60 pg/mL). Tissue cultures and Gram, acid-fast, Fite, and Warthin-Starry stains from the skin biopsy were negative. She was discharged on fluconazole and then readmitted 2 days later with dyspnea, fever, and leukocytosis.

The young woman’s symptoms resolved, only to recur days later; her granulomatous hilar lesions grew larger, and new cutaneous and splenic findings appeared. The granulomatous lesions prompt consideration of infectious, malignant, and immune-mediated processes. The negative cultures make infection less likely, although the elevated β-D-glucan may suggest fungal infection. By description, the skin lesions are consistent with pathergy, a phenomenon characterized by trauma-provoked cutaneous lesions or ulcers, which is associated with numerous syndromes, including Behçet syndrome, inflammatory bowel disease, and neutrophilic dermatoses such as pyoderma gangrenosum (PG) and Sweet syndrome. In addition to details about her medical history, it is important to seek evidence of oral ulcers or vasculitis, as Behçet syndrome may be associated with cutaneous, visceral, and ophthalmologic vasculitis.

Her medical history included hypertension and active, 10-pack-year cigarette use. During childhood, she had occasional ingrown hairs and folliculitis. She did not take medications prior to this acute illness. Family history was notable for cardiovascular disease. She rarely consumed alcohol and did not use illicit drugs. She lived in a rural town in the mid–Willamette Valley of Oregon and worked as an administrative assistant. She spent time outdoors, including trail running and golfing. A case of tularemia was recently reported in an area near her home. Her only travel outside of Oregon was to Puerto Vallarta, Mexico, 16 years previously. She grew up on a farm and had no known tuberculosis exposure.

Tularemia is an interesting diagnostic consideration and could explain her fever, cutaneous lesions, and hilar adenopathy. It is plausible that she had clinically mild pneumonic tularemia at the outset and that her cutaneous lesions are variants of ulceroglandular tularemia. Positive antibodies for Francisella tularensis would be expected if this were the cause of her illness. The ingrown hairs raise the possibility of a primary immune deficiency syndrome predisposing her to abscesses. However, they seem to have been of trivial significance to her, making an immune deficiency syndrome unlikely.

On readmission, she was afebrile, normotensive, and tachycardic (114 beats/min), with a normal respiratory rate and oxygen saturation. She was not ill appearing. She had noninjected conjunctiva and no oral lesions. Apart from tachycardia, cardiovascular examination was unremarkable. Abdominal examination was notable for mild distension and a palpable, tender spleen. Musculoskeletal and neurologic examinations were normal. Her skin was notable for various sized (8 cm × 4 cm to 10 cm × 15 cm) painful ulcers with violaceous, friable borders—some with fluctuance and purulent drainage—on her right hand, bilateral arms, right axilla, sternum, and legs (Figure 1).

JHMVol16No9_Burnett14940915e_f1.JPG

Laboratory studies were notable for normocytic anemia (hemoglobin, 8.9 g/dL; range, 12.0-16.0 g/dL), leukocytosis (white blood cells, 24,900/µL; range, 4500-11,000/µL), thrombocytosis (platelet count, 690,000/µL; range, 150,000-400,000/µL), and elevated inflammatory markers (C-reactive protein, 33 mg/dL; range, <0.5 mg/dL; erythrocyte sedimentation rate, 78 mm/h; range, <20 mm/h). A complete metabolic panel was within normal limits. Repeat blood cultures and β -D-glucan and 16S ribosomal assays were negative. Polymerase chain reaction testing for Bartonella henselae was negative. Urine probes for Neisseria gonorrhoeae and Chlamydia trachomatis were negative. Rapid plasma regain (RPR) was negative. Antibodies to toxoplasmosis, histoplasmosis, blastomycosis, and aspergillosis were unrevealing. A Coccidioides test by immunodiffusion was negative. Serum antigen tests for Cryptococcus and Epstein-Barr virus (EBV) were negative. EBV, HIV, and hepatitis antibody tests were negative. Rheumatologic studies, including antinuclear, anti-double-stranded DNA, anti-Smith, anti–Sjögren syndrome antigens A and B, anticentromere, anti-topoisomerase (anti-Scl-70), anti-histidyl-transfer-RNA-synthetase (anti-Jo-1), and anti-nucleosome (anti-chromatic) antibodies, were unrevealing. Levels of angiotensin-converting enzyme, rheumatoid factor, complement, cytoplasmic, and perinuclear antineutrophil cytoplasmic antibodies were also normal. A neutrophil oxidative burst test was negative. In addition, peripheral flow cytology and serum and urine protein electrophoresis were negative. Chest CT revealed bilateral lower lobe consolidations concerning for necrotizing pneumonia, splenic enlargement, numerous hypodense splenic lesions, and a 1.3-cm right hilar node, which had decreased in size compared with 1 month prior.

In summary, the patient presented with recurrent upper respiratory symptoms, fever, and abdominal pain; expanding granulomatous hilar lesions, splenomegaly, and cutaneous lesions consistent with pathergy; elevated inflammatory markers and leukocytosis; and a possible exposure to F tularensis. She has had extensive negative infectious workups, except for a weakly positive β-D-glucan, and completed several courses of apparently unhelpful antimicrobials. At this point, the most notable findings are her splenomegaly and inflammatory masses suggesting an inflammatory process, which may be autoimmune in nature. Both vasculitis and sarcoidosis remain possibilities, and malignancy is possible. Given her possible exposure to F tularensis, obtaining serum antibodies to F tularensis, in addition to biopsies of the skin lesions, is advisable.

Laboratory studies revealed a positive F tularensis antibody with a titer of 1:320 and an IgM of 7 U/mL and IgG of 30 U/mL. This was repeated, revealing a titer of 1:540 and an IgM and IgG of 5 U/mL and 20 U/mL, respectively. Given the potential exposure history, the clinical syndrome compatible with tularemia, and an otherwise extensive yet unrevealing evaluation, she was treated with a 10-day course of streptomycin. Her fever persisted, and the splenic lesions increased in size and number, prompting addition of moxifloxacin without apparent benefit. Skin biopsies taken from the patient’s arm were notable for nodular, suppurative, neutrophilic infiltrates and histiocytes in the medium and deep dermis without multinucleated histiocytes or evidence of vasculitis. Fungal, mycobacterial, and bacterial stains from the biopsy were negative. The findings were consistent with but not diagnostic of an acute neutrophilic dermatosis.

At this point, the patient has a confirmed exposure to F tularensis; she also has persistent fever, progressive splenomegaly, and new skin biopsies consistent with neutrophilic dermatosis. Despite the F tularensis antibody positivity, her negative cultures and lack of improvement with multiple courses of antimicrobials argue against an infectious etiology. Accordingly, malignancy should be considered but seems less likely given that no laboratory, imaging, or tissue samples support it. This leaves immune-mediated etiologies, especially autoimmune conditions associated with neutrophilic dermatoses, as the most likely explanation of her inflammatory syndrome. Neutrophilic dermatoses include some vasculitides, Sweet syndrome, PG, Behçet syndrome, and other inflammatory entities. She has no evidence of vasculitis on biopsy. Given the evidence of inflammation and the history of pathergy, Behçet syndrome and PG should be seriously considered.

She underwent incision and drainage of the left leg and mediastinal lesions. A follow-up chest CT revealed stable cutaneous and deep tissue lesions and continued splenic enlargement. She was started on prednisone and dapsone for presumed cutaneous and visceral PG. The lesions improved dramatically and, following a month-long hospitalization, she was discharged on dapsone and a slow prednisone taper. Three weeks after discharge, while on dapsone and prednisone, she developed a new skin lesion. Cyclosporine was added, with improvement. Eight weeks after discharge, she developed fever, acute left-upper-quadrant pain, and marked splenomegaly with abscesses seen on CT imaging (Figure 2).

JHMVol16No9_Burnett14940915e_f2.JPG

This continues to be a very puzzling case, and it is worth revisiting her clinical course once again. This is a previously healthy 32-year-old woman with multiple hospital presentations for upper-respiratory symptoms, persistent fever, abdominal pain, and painful cutaneous lesions consistent with pathergy; she was found to have granulomatous hilar lesions, progressive splenomegaly, and skin biopsies consistent with neutrophilic dermatosis. Exhaustive infectious and rheumatologic workup was negative, and no evident malignancy was found. Finally, despite multiple courses of antimicrobials, including standard treatments for tularemia (for which she had positive antibodies), her clinical course failed to improve until the addition of systemic anti-inflammatory agents, which resulted in rapid improvement. She then presented 8 weeks later with recurrent fever and splenomegaly. Given the recurrence and the severity of the splenic pathology, a diagnostic splenectomy is advisable for what appears to be visceral PG. In addition, attempting to identify a trigger of her syndrome is important. PG can be associated with inflammatory bowel disease, hematologic disorders (eg, leukemia, myeloma, myelodysplastic syndrome, and myelofibrosis), and autoimmune diseases, especially inflammatory arthritis.¹ Therefore, a diagnostic colonoscopy and bone marrow biopsy should be considered. With no history or examination supporting inflammatory arthritis and a broad, unrevealing workup, her rheumatologic evaluation is sufficient.

The patient underwent splenectomy. Gross description of the spleen was notable for multiple abscesses, consisting on microscopy of large areas of necrosis with islands of dense neutrophil collections (Figure 3). Microscopic examination failed to demonstrate microorganisms on multiple stains, and there was no microscopic or flow cytometric evidence of lymphoma. The final pathologic diagnosis was multiple sterile splenic abscesses with siderosis, which, in the context of her overall syndrome, was consistent with an entity termed aseptic abscess syndrome (AAS). After discharge, she underwent a slow steroid taper and was ultimately maintained on daily low-dose prednisone. Cyclosporine and dapsone were discontinued in favor of infliximab infusions. She underwent additional diagnostic workup, including an unremarkable colonoscopy and a bone marrow biopsy, which showed monoclonal gammopathy of undetermined significance (MGUS) with an insignificant IgA monoclonal gammopathy. All cutaneous lesions healed. Three years after the splenectomy, while still on infliximab and prednisone, she developed a new aseptic lung abscess, which resolved after increasing her prednisone dose. Six years after splenectomy, she developed an aseptic liver abscess, which resolved after again increasing the frequency of her infliximab infusions.

JHMVol16No9_Burnett14940915e_f3.JPG

Diagnostic uncertainty is an intrinsic feature of medical practice—in part because patients often present with undifferentiated and evolving symptoms.² When faced with uncertainty, clinicians are well served by prioritizing a thoughtful differential diagnosis, adopting a stepwise management strategy, and engaging in iterative reassessments of the patient. In this case, a 32-year-old, previously healthy woman presented with an array of symptoms, including abdominal pain, fever, leukocytosis, necrotic skin lesions, necrotizing mediastinal lymphadenitis, pathergy, and splenomegaly. Elements of the history, examination, and diagnostic studies supported a differential diagnosis of tularemia, PG, and AAS. Through stepwise management and ongoing reassessment, she was ultimately diagnosed with AAS.

Tularemia was initially an important diagnostic consideration in this patient, given her potential exposure and positive F tularensis serum antibodies. Francisella tularensis is a Gram-negative coccobacillus found in more than 250 species of fish, ticks, birds, and mammals. In humans, an incubation period of 3 to 5 days is typical. Although clinical manifestations vary, they often include fever, headache, and malaise.³ Other findings may include lymphadenopathy with or without ulcerative cutaneous lesions (glandular or ulceroglandular tularemia) and cough, dyspnea, pleuritic chest pain, and hilar adenopathy (pneumonic tularemia). As noted by the discussant, a pneumonic tularemia syndrome could have explained this patient’s fever, respiratory symptoms, and hilar adenopathy; ulceroglandular tularemia might have explained her cutaneous lesions. Since splenomegaly may be seen in tularemia, this finding was also consistent with the diagnosis. Serum antibody testing is supportive of the diagnosis, while culture confirms it. Standard treatment consists of a 10- to 14-day course of streptomycin, and combination therapy with a fluoroquinolone is recommended in severe cases.⁴ In this patient, however, F tularensis was not demonstrated on culture. Furthermore, she did not experience the expected clinical improvement with treatment. Finally, because both IgG and IgM tularemia antibodies may co-occur up to 10 years following infection, her positive F tularensis serum antibodies did not provide evidence of acute infection.⁵

Recognizing inconsistencies in the diagnosis of tularemia, the focus shifted to PG owing to the patient’s neutrophilic cutaneous lesions, negative infectious workup, and pathergy. Pyoderma gangrenosum is a neutrophilic dermatosis—one of a heterogeneous group of skin conditions characterized by perivascular and diffuse neutrophilic infiltrates without an identifiable infectious agent.⁶ It is a chronic, recurrent cutaneous disease with several variants.⁷ The classic presentation includes painful lower-extremity ulcers with violaceous undermined borders and may be associated with pathergy. Guiding principles for the management of PG include controlling inflammation, optimizing wound healing, and minimizing exacerbating factors.¹ As such, treatment mainstays include local and systemic anti-inflammatory agents and wound care. As the discussant highlighted, in this case the inflammatory skin lesions were suggestive of PG. However, other features of the case, notably, splenomegaly, splenic abscesses, and necrotizing mediastinal lymphadenitis, were more consistent with another diagnosis: AAS. Aseptic abscess syndrome is an autoinflammatory disorder defined by deep, noninfectious abscesses that preferentially affect the spleen.⁸ Additional clinical manifestations include weight loss, fever, abdominal pain, and leukocytosis. Lesions may also affect bone, kidney, liver, lung, lymph node, and skin. In one case series, neutrophilic dermatoses were seen in 20% of AAS cases.⁸ In all cases of AAS, extensive infectious workup is unrevealing, and antibiotics are ineffective. The pathophysiology of AAS is unknown.

Similar to PG, the majority of AAS cases are associated with inflammatory bowel disease, especially Crohn disease.⁹ However, AAS also has associations with conditions such as MGUS, rheumatoid arthritis, spondyloarthritis, and relapsing polychondritis. Histologically, early lesions demonstrate a necrotic core of neutrophils, with or without surrounding palisading histiocytes, and giant cells. In older lesions, neutrophils may be absent; fibrous tissue may be present.⁸ Treatment regimens include splenectomy, corticosteroids, colchicine, thalidomide, tumor necrosis factor (TNF) antagonists, and cyclophosphamide. The discussant astutely recommended a splenectomy for this patient, which was both diagnostic and therapeutic. As in this case, relapse is common. Optimal maintenance therapy is yet to be determined.⁹

Given the overlapping clinical manifestations, shared disease associations, and similar responsiveness to immunosuppression, it is unclear whether AAS represents a new disease entity or a variant of known autoinflammatory disorders. Aseptic abscess syndrome is likely part of a spectrum of autoinflammatory disorders with inflammatory bowel diseases, neutrophilic dermatoses, and other similar diseases.⁸ While infectious visceral abscesses remain more common, this case highlights the clinical manifestation of an emerging and likely underrecognized entity.

• Aseptic abscess syndrome should be considered in patients who present with visceral (particularly splenic) abscesses and negative infectious workup.
• Aseptic abscess syndrome is commonly associated with other autoinflammatory disorders; the majority of reported cases are associated with inflammatory bowel disease, especially Crohn disease.
• Up to 20% of AAS cases are associated with neutrophilic dermatoses such as PG.
• The initial treatment for this syndrome is high-dose intravenous glucocorticoids; maintenance treatment regimens include corticosteroids, colchicine, thalidomide, TNF antagonists, and cyclophosphamide.

The authors would thank Dr Bob Pelz and Dr John Townes for their contributions to the case.

Earlier this year, the Journal of Hospital Medicine updated its author guidelines to include recommendations on addressing race and racism.¹ These recommendations include explicitly naming racism (rather than race) as a determinant of health. Operationalizing these recommendations into manuscripts represents a fundamental shift in how we ask research questions, structure analyses, and interpret results.

In this issue, Maxwell et al² illustrate how to disseminate research through this lens in their retrospective cohort study of children with type 1 diabetes hospitalized with diabetic ketoacidosis (DKA). Using 6 years of data from a major academic pediatric medical center, the authors examine the association between risk for DKA admission and three factors: neighborhood poverty level, race, and type of insurance (public or private). Secondary outcomes include DKA severity and length of stay. In their unadjusted model, poverty, race, and insurance were all associated with increased hospitalizations. However, following adjustment, the association between race and hospitalizations disappeared.In line with the journal’s new guidelines, the authors point out that the statistically significant associations of poverty and insurance type with clinical outcomes suggest that racism, rather than race, is a social factor at work in their population. The authors provide further context regarding structural racism in the United States and the history of redlining, which has helped shape a society in which Black individuals are more likely to live in areas of concentrated poverty and be publicly insured.

Two other findings related to the impact of racism are notable. First, in both their univariate and multivariate models, the authors found significant A1c differences between Black and White children—higher than those of previous reports.³ These findings suggest the existence of structural factors at work in the health of their patients. Second, Black patients had longer lengths of stay when compared to White patients with the same severity of DKA. Neither poverty level nor insurance status were significantly associated with length of stay. While the analysis was limited to detecting this difference, rather than identifying its causes, the authors suggest factors at both individual and structural levels that may be impacting outcomes. Specifically, care team bias may impact discharge decisions, and factors such as less flexible times to complete diabetes education, transportation barriers, and childcare challenges could also impact discharge timing.

This work provides a template for how to address the impact of racism on health with intentionality. Moreover, individuals’ lived environments should be considered through alternative economic measurements and neighborhood definitions. The proportion of people within a census tract living below the federal poverty line is just one measure of the complex dynamics that contribute to an individual’s socioeconomic status. An alternative measure is the area deprivation index, which incorporates 17 indicators at the more granular census block group level to describe an individual’s environment⁴ and could be useful in this area of research.

Perhaps most relevant is the use of public insurance as a marker of socioeconomic status. Medicaid, although not without its flaws, provides fairly comprehensive coverage. However, many Americans have incomes too high to qualify for public insurance but too low to afford adequate insurance coverage. Theoretically, these individuals qualify for subsidies through the Affordable Care Act, yet underinsurance remains a significant issue.⁵ Future analyses to further understand and describe clinical outcomes could include this population of underinsured children as a distinct at-risk group. Maxwell et al² provide an excellent example of how we should address race and racism in disseminated literature. Although initially challenging, writing with intentionality regarding this fundamental determinant of health can provide rich and actionable information for practitioners and policy-makers.

Earlier this year, the Journal of Hospital Medicine updated its author guidelines to include recommendations on addressing race and racism.¹ These recommendations include explicitly naming racism (rather than race) as a determinant of health. Operationalizing these recommendations into manuscripts represents a fundamental shift in how we ask research questions, structure analyses, and interpret results.

In this issue, Maxwell et al² illustrate how to disseminate research through this lens in their retrospective cohort study of children with type 1 diabetes hospitalized with diabetic ketoacidosis (DKA). Using 6 years of data from a major academic pediatric medical center, the authors examine the association between risk for DKA admission and three factors: neighborhood poverty level, race, and type of insurance (public or private). Secondary outcomes include DKA severity and length of stay. In their unadjusted model, poverty, race, and insurance were all associated with increased hospitalizations. However, following adjustment, the association between race and hospitalizations disappeared.In line with the journal’s new guidelines, the authors point out that the statistically significant associations of poverty and insurance type with clinical outcomes suggest that racism, rather than race, is a social factor at work in their population. The authors provide further context regarding structural racism in the United States and the history of redlining, which has helped shape a society in which Black individuals are more likely to live in areas of concentrated poverty and be publicly insured.

Two other findings related to the impact of racism are notable. First, in both their univariate and multivariate models, the authors found significant A1c differences between Black and White children—higher than those of previous reports.³ These findings suggest the existence of structural factors at work in the health of their patients. Second, Black patients had longer lengths of stay when compared to White patients with the same severity of DKA. Neither poverty level nor insurance status were significantly associated with length of stay. While the analysis was limited to detecting this difference, rather than identifying its causes, the authors suggest factors at both individual and structural levels that may be impacting outcomes. Specifically, care team bias may impact discharge decisions, and factors such as less flexible times to complete diabetes education, transportation barriers, and childcare challenges could also impact discharge timing.

This work provides a template for how to address the impact of racism on health with intentionality. Moreover, individuals’ lived environments should be considered through alternative economic measurements and neighborhood definitions. The proportion of people within a census tract living below the federal poverty line is just one measure of the complex dynamics that contribute to an individual’s socioeconomic status. An alternative measure is the area deprivation index, which incorporates 17 indicators at the more granular census block group level to describe an individual’s environment⁴ and could be useful in this area of research.

Perhaps most relevant is the use of public insurance as a marker of socioeconomic status. Medicaid, although not without its flaws, provides fairly comprehensive coverage. However, many Americans have incomes too high to qualify for public insurance but too low to afford adequate insurance coverage. Theoretically, these individuals qualify for subsidies through the Affordable Care Act, yet underinsurance remains a significant issue.⁵ Future analyses to further understand and describe clinical outcomes could include this population of underinsured children as a distinct at-risk group. Maxwell et al² provide an excellent example of how we should address race and racism in disseminated literature. Although initially challenging, writing with intentionality regarding this fundamental determinant of health can provide rich and actionable information for practitioners and policy-makers.

Earlier this year, the Journal of Hospital Medicine updated its author guidelines to include recommendations on addressing race and racism.¹ These recommendations include explicitly naming racism (rather than race) as a determinant of health. Operationalizing these recommendations into manuscripts represents a fundamental shift in how we ask research questions, structure analyses, and interpret results.

In this issue, Maxwell et al² illustrate how to disseminate research through this lens in their retrospective cohort study of children with type 1 diabetes hospitalized with diabetic ketoacidosis (DKA). Using 6 years of data from a major academic pediatric medical center, the authors examine the association between risk for DKA admission and three factors: neighborhood poverty level, race, and type of insurance (public or private). Secondary outcomes include DKA severity and length of stay. In their unadjusted model, poverty, race, and insurance were all associated with increased hospitalizations. However, following adjustment, the association between race and hospitalizations disappeared.In line with the journal’s new guidelines, the authors point out that the statistically significant associations of poverty and insurance type with clinical outcomes suggest that racism, rather than race, is a social factor at work in their population. The authors provide further context regarding structural racism in the United States and the history of redlining, which has helped shape a society in which Black individuals are more likely to live in areas of concentrated poverty and be publicly insured.

Two other findings related to the impact of racism are notable. First, in both their univariate and multivariate models, the authors found significant A1c differences between Black and White children—higher than those of previous reports.³ These findings suggest the existence of structural factors at work in the health of their patients. Second, Black patients had longer lengths of stay when compared to White patients with the same severity of DKA. Neither poverty level nor insurance status were significantly associated with length of stay. While the analysis was limited to detecting this difference, rather than identifying its causes, the authors suggest factors at both individual and structural levels that may be impacting outcomes. Specifically, care team bias may impact discharge decisions, and factors such as less flexible times to complete diabetes education, transportation barriers, and childcare challenges could also impact discharge timing.

This work provides a template for how to address the impact of racism on health with intentionality. Moreover, individuals’ lived environments should be considered through alternative economic measurements and neighborhood definitions. The proportion of people within a census tract living below the federal poverty line is just one measure of the complex dynamics that contribute to an individual’s socioeconomic status. An alternative measure is the area deprivation index, which incorporates 17 indicators at the more granular census block group level to describe an individual’s environment⁴ and could be useful in this area of research.

Perhaps most relevant is the use of public insurance as a marker of socioeconomic status. Medicaid, although not without its flaws, provides fairly comprehensive coverage. However, many Americans have incomes too high to qualify for public insurance but too low to afford adequate insurance coverage. Theoretically, these individuals qualify for subsidies through the Affordable Care Act, yet underinsurance remains a significant issue.⁵ Future analyses to further understand and describe clinical outcomes could include this population of underinsured children as a distinct at-risk group. Maxwell et al² provide an excellent example of how we should address race and racism in disseminated literature. Although initially challenging, writing with intentionality regarding this fundamental determinant of health can provide rich and actionable information for practitioners and policy-makers.

We are committed to using our platform at the Journal of Hospital Medicine (JHM) to address inequities in healthcare delivery, policy, and research. Race was conceived as a mechanism of social division, leading to the false belief, propagated over time, of race as a biological variable.¹ As a result, racism has contributed to the medical abuse and exploitation of Black and Brown communities and inequities in health status among racialized groups. We must abandon practices that perpetuate inequities and champion practices that resolve them. Racial health equity—the absence of unjust and avoidable health disparities among racialized groups—is unattainable if we continue to simply identify inequities without naming racism as a determinant of health. As a journal, our responsibility is to disseminate evidence-based manuscripts that reflect an understanding of race, racism, and health.

We have modified our author guidelines. First, we now require authors to clearly define race and provide justification for its inclusion in clinical case descriptions and study analyses. We aim to contribute to the necessary course correction as well as promote self-reflection on study design choices that propagate false notions of race as a biological concept and conclusions that reinforce race-based rather than race-conscious practices in medicine.² Second, we expect authors to explicitly name racism and make a concerted effort to explore its role, identify its specific forms, and examine mutually reinforcing mechanisms of inequity that potentially contributed to study findings. Finally, we instruct authors to avoid the use of phrases like “patient mistrust,” which places blame for inequities on patients and their families and decouples mistrust from the fraught history of racism in medicine.

We must also acknowledge and reflect on our previous contributions to such inequity as authors, reviewers, and editors in order to learn and grow. Among the more than 2,000 articles published in JHM since its inception, only four included the term “racism.” Three of these articles are perspectives published in June 2020 and beyond. The only original research manuscript that directly addressed racism was a qualitative study of adults with sickle cell disease.³ The authors described study participants’ perspectives: “In contrast, the hospital experience during adulthood was often punctuated by bitter relationships with staff, and distrust over possible excessive use of opioids. Moreover, participants raised the possibility of racism in their interactions with hospital staff.” In this example, patients called out racism and its impact on their experience. We know JHM is not alone in falling woefully short in advancing our understanding of racism and racial health inequities. Each of us should identify missed opportunities to call out racism as a driver of racial health disparities in our own publications. We must act on these lessons regarding the ways in which racism infiltrates scientific publishing. We must use this awareness, along with our influence, voice, and collective power, to enact change for the betterment of our patients, their families, and the medical community.

We at JHM will contribute to uncovering and disseminating solutions to health inequities that result from racism. We are grateful to Boyd et al for their call to action and for providing a blueprint for improvement to those of us who write, review, and publish scholarly work.⁴

We are committed to using our platform at the Journal of Hospital Medicine (JHM) to address inequities in healthcare delivery, policy, and research. Race was conceived as a mechanism of social division, leading to the false belief, propagated over time, of race as a biological variable.¹ As a result, racism has contributed to the medical abuse and exploitation of Black and Brown communities and inequities in health status among racialized groups. We must abandon practices that perpetuate inequities and champion practices that resolve them. Racial health equity—the absence of unjust and avoidable health disparities among racialized groups—is unattainable if we continue to simply identify inequities without naming racism as a determinant of health. As a journal, our responsibility is to disseminate evidence-based manuscripts that reflect an understanding of race, racism, and health.

We have modified our author guidelines. First, we now require authors to clearly define race and provide justification for its inclusion in clinical case descriptions and study analyses. We aim to contribute to the necessary course correction as well as promote self-reflection on study design choices that propagate false notions of race as a biological concept and conclusions that reinforce race-based rather than race-conscious practices in medicine.² Second, we expect authors to explicitly name racism and make a concerted effort to explore its role, identify its specific forms, and examine mutually reinforcing mechanisms of inequity that potentially contributed to study findings. Finally, we instruct authors to avoid the use of phrases like “patient mistrust,” which places blame for inequities on patients and their families and decouples mistrust from the fraught history of racism in medicine.

We must also acknowledge and reflect on our previous contributions to such inequity as authors, reviewers, and editors in order to learn and grow. Among the more than 2,000 articles published in JHM since its inception, only four included the term “racism.” Three of these articles are perspectives published in June 2020 and beyond. The only original research manuscript that directly addressed racism was a qualitative study of adults with sickle cell disease.³ The authors described study participants’ perspectives: “In contrast, the hospital experience during adulthood was often punctuated by bitter relationships with staff, and distrust over possible excessive use of opioids. Moreover, participants raised the possibility of racism in their interactions with hospital staff.” In this example, patients called out racism and its impact on their experience. We know JHM is not alone in falling woefully short in advancing our understanding of racism and racial health inequities. Each of us should identify missed opportunities to call out racism as a driver of racial health disparities in our own publications. We must act on these lessons regarding the ways in which racism infiltrates scientific publishing. We must use this awareness, along with our influence, voice, and collective power, to enact change for the betterment of our patients, their families, and the medical community.

We at JHM will contribute to uncovering and disseminating solutions to health inequities that result from racism. We are grateful to Boyd et al for their call to action and for providing a blueprint for improvement to those of us who write, review, and publish scholarly work.⁴

We are committed to using our platform at the Journal of Hospital Medicine (JHM) to address inequities in healthcare delivery, policy, and research. Race was conceived as a mechanism of social division, leading to the false belief, propagated over time, of race as a biological variable.¹ As a result, racism has contributed to the medical abuse and exploitation of Black and Brown communities and inequities in health status among racialized groups. We must abandon practices that perpetuate inequities and champion practices that resolve them. Racial health equity—the absence of unjust and avoidable health disparities among racialized groups—is unattainable if we continue to simply identify inequities without naming racism as a determinant of health. As a journal, our responsibility is to disseminate evidence-based manuscripts that reflect an understanding of race, racism, and health.

We have modified our author guidelines. First, we now require authors to clearly define race and provide justification for its inclusion in clinical case descriptions and study analyses. We aim to contribute to the necessary course correction as well as promote self-reflection on study design choices that propagate false notions of race as a biological concept and conclusions that reinforce race-based rather than race-conscious practices in medicine.² Second, we expect authors to explicitly name racism and make a concerted effort to explore its role, identify its specific forms, and examine mutually reinforcing mechanisms of inequity that potentially contributed to study findings. Finally, we instruct authors to avoid the use of phrases like “patient mistrust,” which places blame for inequities on patients and their families and decouples mistrust from the fraught history of racism in medicine.

We must also acknowledge and reflect on our previous contributions to such inequity as authors, reviewers, and editors in order to learn and grow. Among the more than 2,000 articles published in JHM since its inception, only four included the term “racism.” Three of these articles are perspectives published in June 2020 and beyond. The only original research manuscript that directly addressed racism was a qualitative study of adults with sickle cell disease.³ The authors described study participants’ perspectives: “In contrast, the hospital experience during adulthood was often punctuated by bitter relationships with staff, and distrust over possible excessive use of opioids. Moreover, participants raised the possibility of racism in their interactions with hospital staff.” In this example, patients called out racism and its impact on their experience. We know JHM is not alone in falling woefully short in advancing our understanding of racism and racial health inequities. Each of us should identify missed opportunities to call out racism as a driver of racial health disparities in our own publications. We must act on these lessons regarding the ways in which racism infiltrates scientific publishing. We must use this awareness, along with our influence, voice, and collective power, to enact change for the betterment of our patients, their families, and the medical community.

We at JHM will contribute to uncovering and disseminating solutions to health inequities that result from racism. We are grateful to Boyd et al for their call to action and for providing a blueprint for improvement to those of us who write, review, and publish scholarly work.⁴

The transition of children from hospital to home introduces a unique set of challenges to patients and families who may not be well-versed in the healthcare system. In addition to juggling the stress and worry of a sick child, which can inhibit the ability to understand complicated discharge instructions prior to leaving the hospital,¹ caregivers need to navigate the medical system to ensure continued recovery. The responsibility to fill and administer medications, arrange follow up appointments, and determine when to seek care if the child’s condition changes are burdens we as healthcare providers expect caregivers to manage but may underestimate how frequently they are reliably completed.^2-4

In this issue of the Journal of Hospital Medicine, the article by Rehm et al.⁵ adds to the growing body of evidence highlighting challenges that caregivers of children face upon discharge from the hospital. The multicenter, retrospective study of postdischarge encounters for over 12,000 patients discharged from 4 children’s hospitals aimed to evaluate the following: (1) various methods for hospital-initiated postdischarge contact of families, (2) the type and frequency of postdischarge issues, and (3) specific characteristics of pediatric patients most commonly affected by postdischarge issues.

Using standardized questions administered through telephone, text, or e-mail contact, postdischarge issues were identified in 25% of discharges across all hospitals. Notably, there was considerable variation of rates of postdischarge issues among hospitals (from 16% to 62.8%). The hospital with the highest rate of postdischarge issues identified had attending hospitalists calling families after discharge. Thus, postdischarge issues may be most easily identified by providers who are familiar with both the patient and the expected postdischarge care.

Often, postdischarge issues represented events that could be mitigated with intentional planning to better anticipate and address patient and family needs prior to discharge. The vast majority of postdischarge issues identified across all hospitals were related to appointments, accounting for 76.3% of postdischarge issues, which may be attributed to a variety of causes, from inadequate or unclear provider recommendations to difficulty scheduling the appointments. The most common medication postdischarge issue was difficulty filling prescriptions, accounting for 84.8% of the medication issues. “Other” postdischarge issues (12.7%) as reported by caregivers included challenges with understanding discharge instructions and concerns about changes in their child’s clinical status. Forty percent of included patients had a chronic care condition. Older children, patients with more medication classes, shorter length of stay, and neuromuscular chronic care conditions had higher odds of postdischarge issues. Although a high proportion of postdischarge issues suggests a systemic problem addressing the needs of patients and families after hospital discharge, these data likely underestimate the magnitude of the problem; as such, the need for improvement may be higher.

Postdischarge challenges faced by families are not unique to pediatrics. Pediatric and adult medical patients face similar rates of challenges after hospital discharge.^6,7 In adults, the preventable nature of unexpected incidents, such as adverse drug events, occur most frequently.⁶ The inability to keep appointments and troubleshoot problems by knowing who to contact after discharge also emerged in adult studies as factors that may lead to preventable readmissions.⁸ Furthermore, a lack of direct, effective communication between inpatient and outpatient providers has been cited as a driving force behind poor care transitions.^6,9

Given the prevalence of postdischarge issues after both pediatric and adult hospitalizations, how should hospitalists proceed? Physicians and health systems should explore approaches to better prepare caregivers, perhaps using models akin to the Seamless Transitions and (Re)admissions Network model of enhanced communication, care coordination, and family engagement.¹⁰ Pediatric hospitalists can prepare children for discharge long before departure by delivering medications to patients prior to discharge,^11,12 providing discharge instructions that are clear and readable,^13,14 as well as utilizing admission-discharge teaching nurses,¹⁵ inpatient care managers,^16,17 and pediatric nurse practitioners¹⁸ to aid transition.

While a variety of interventions show promise in securing a successful transition to home from the hospitalist vantage point, a partnership with primary care physicians (PCPs) in our communities is paramount. Though the evidence linking gaps in primary care after discharge and readmission rates remain elusive, effective partnerships with PCPs are important for ensuring discharge plans are carried out, which may ultimately lead to decreased rates of unanticipated adverse outcomes. Several adult studies note that no single intervention is likely to prevent issues after discharge, but interventions should include high-quality communication with and involvement of community partners.^9,19,20 In practice, providing a high-quality, reliable handoff can be difficult given competing priorities of busy outpatient clinic schedules and inpatient bed capacity concerns, necessitating efficient discharge practices. Some of these challenges are amenable to quality improvement efforts to improve discharge communication.²¹ Innovative ideas include collaborating with PCPs earlier in the admission to design the care plan up front, including PCPs in weekly team meetings for patients with chronic care conditions,^16,17 and using telehealth to communicate with PCPs.

Ensuring a safe transition to home is our responsibility as hospitalists, but the solutions to doing so reliably require multi-fold interventions that build teams within hospitals, innovative outreach to those patients recently discharged to ensure their well-being and mitigate postdischarge issues and broad community programs—including greater access to primary care—to meet our urgent imperative.

Disclosure

The authors declare no conflicts of interest. Dr. Auger’s research is funded by the Agency for Healthcare Research and Quality (1K08HS024735).

The transition of children from hospital to home introduces a unique set of challenges to patients and families who may not be well-versed in the healthcare system. In addition to juggling the stress and worry of a sick child, which can inhibit the ability to understand complicated discharge instructions prior to leaving the hospital,¹ caregivers need to navigate the medical system to ensure continued recovery. The responsibility to fill and administer medications, arrange follow up appointments, and determine when to seek care if the child’s condition changes are burdens we as healthcare providers expect caregivers to manage but may underestimate how frequently they are reliably completed.^2-4

In this issue of the Journal of Hospital Medicine, the article by Rehm et al.⁵ adds to the growing body of evidence highlighting challenges that caregivers of children face upon discharge from the hospital. The multicenter, retrospective study of postdischarge encounters for over 12,000 patients discharged from 4 children’s hospitals aimed to evaluate the following: (1) various methods for hospital-initiated postdischarge contact of families, (2) the type and frequency of postdischarge issues, and (3) specific characteristics of pediatric patients most commonly affected by postdischarge issues.

Using standardized questions administered through telephone, text, or e-mail contact, postdischarge issues were identified in 25% of discharges across all hospitals. Notably, there was considerable variation of rates of postdischarge issues among hospitals (from 16% to 62.8%). The hospital with the highest rate of postdischarge issues identified had attending hospitalists calling families after discharge. Thus, postdischarge issues may be most easily identified by providers who are familiar with both the patient and the expected postdischarge care.

Often, postdischarge issues represented events that could be mitigated with intentional planning to better anticipate and address patient and family needs prior to discharge. The vast majority of postdischarge issues identified across all hospitals were related to appointments, accounting for 76.3% of postdischarge issues, which may be attributed to a variety of causes, from inadequate or unclear provider recommendations to difficulty scheduling the appointments. The most common medication postdischarge issue was difficulty filling prescriptions, accounting for 84.8% of the medication issues. “Other” postdischarge issues (12.7%) as reported by caregivers included challenges with understanding discharge instructions and concerns about changes in their child’s clinical status. Forty percent of included patients had a chronic care condition. Older children, patients with more medication classes, shorter length of stay, and neuromuscular chronic care conditions had higher odds of postdischarge issues. Although a high proportion of postdischarge issues suggests a systemic problem addressing the needs of patients and families after hospital discharge, these data likely underestimate the magnitude of the problem; as such, the need for improvement may be higher.

Postdischarge challenges faced by families are not unique to pediatrics. Pediatric and adult medical patients face similar rates of challenges after hospital discharge.^6,7 In adults, the preventable nature of unexpected incidents, such as adverse drug events, occur most frequently.⁶ The inability to keep appointments and troubleshoot problems by knowing who to contact after discharge also emerged in adult studies as factors that may lead to preventable readmissions.⁸ Furthermore, a lack of direct, effective communication between inpatient and outpatient providers has been cited as a driving force behind poor care transitions.^6,9

Given the prevalence of postdischarge issues after both pediatric and adult hospitalizations, how should hospitalists proceed? Physicians and health systems should explore approaches to better prepare caregivers, perhaps using models akin to the Seamless Transitions and (Re)admissions Network model of enhanced communication, care coordination, and family engagement.¹⁰ Pediatric hospitalists can prepare children for discharge long before departure by delivering medications to patients prior to discharge,^11,12 providing discharge instructions that are clear and readable,^13,14 as well as utilizing admission-discharge teaching nurses,¹⁵ inpatient care managers,^16,17 and pediatric nurse practitioners¹⁸ to aid transition.

While a variety of interventions show promise in securing a successful transition to home from the hospitalist vantage point, a partnership with primary care physicians (PCPs) in our communities is paramount. Though the evidence linking gaps in primary care after discharge and readmission rates remain elusive, effective partnerships with PCPs are important for ensuring discharge plans are carried out, which may ultimately lead to decreased rates of unanticipated adverse outcomes. Several adult studies note that no single intervention is likely to prevent issues after discharge, but interventions should include high-quality communication with and involvement of community partners.^9,19,20 In practice, providing a high-quality, reliable handoff can be difficult given competing priorities of busy outpatient clinic schedules and inpatient bed capacity concerns, necessitating efficient discharge practices. Some of these challenges are amenable to quality improvement efforts to improve discharge communication.²¹ Innovative ideas include collaborating with PCPs earlier in the admission to design the care plan up front, including PCPs in weekly team meetings for patients with chronic care conditions,^16,17 and using telehealth to communicate with PCPs.

Ensuring a safe transition to home is our responsibility as hospitalists, but the solutions to doing so reliably require multi-fold interventions that build teams within hospitals, innovative outreach to those patients recently discharged to ensure their well-being and mitigate postdischarge issues and broad community programs—including greater access to primary care—to meet our urgent imperative.

Disclosure

The authors declare no conflicts of interest. Dr. Auger’s research is funded by the Agency for Healthcare Research and Quality (1K08HS024735).

The transition of children from hospital to home introduces a unique set of challenges to patients and families who may not be well-versed in the healthcare system. In addition to juggling the stress and worry of a sick child, which can inhibit the ability to understand complicated discharge instructions prior to leaving the hospital,¹ caregivers need to navigate the medical system to ensure continued recovery. The responsibility to fill and administer medications, arrange follow up appointments, and determine when to seek care if the child’s condition changes are burdens we as healthcare providers expect caregivers to manage but may underestimate how frequently they are reliably completed.^2-4

In this issue of the Journal of Hospital Medicine, the article by Rehm et al.⁵ adds to the growing body of evidence highlighting challenges that caregivers of children face upon discharge from the hospital. The multicenter, retrospective study of postdischarge encounters for over 12,000 patients discharged from 4 children’s hospitals aimed to evaluate the following: (1) various methods for hospital-initiated postdischarge contact of families, (2) the type and frequency of postdischarge issues, and (3) specific characteristics of pediatric patients most commonly affected by postdischarge issues.

Using standardized questions administered through telephone, text, or e-mail contact, postdischarge issues were identified in 25% of discharges across all hospitals. Notably, there was considerable variation of rates of postdischarge issues among hospitals (from 16% to 62.8%). The hospital with the highest rate of postdischarge issues identified had attending hospitalists calling families after discharge. Thus, postdischarge issues may be most easily identified by providers who are familiar with both the patient and the expected postdischarge care.

Often, postdischarge issues represented events that could be mitigated with intentional planning to better anticipate and address patient and family needs prior to discharge. The vast majority of postdischarge issues identified across all hospitals were related to appointments, accounting for 76.3% of postdischarge issues, which may be attributed to a variety of causes, from inadequate or unclear provider recommendations to difficulty scheduling the appointments. The most common medication postdischarge issue was difficulty filling prescriptions, accounting for 84.8% of the medication issues. “Other” postdischarge issues (12.7%) as reported by caregivers included challenges with understanding discharge instructions and concerns about changes in their child’s clinical status. Forty percent of included patients had a chronic care condition. Older children, patients with more medication classes, shorter length of stay, and neuromuscular chronic care conditions had higher odds of postdischarge issues. Although a high proportion of postdischarge issues suggests a systemic problem addressing the needs of patients and families after hospital discharge, these data likely underestimate the magnitude of the problem; as such, the need for improvement may be higher.

Postdischarge challenges faced by families are not unique to pediatrics. Pediatric and adult medical patients face similar rates of challenges after hospital discharge.^6,7 In adults, the preventable nature of unexpected incidents, such as adverse drug events, occur most frequently.⁶ The inability to keep appointments and troubleshoot problems by knowing who to contact after discharge also emerged in adult studies as factors that may lead to preventable readmissions.⁸ Furthermore, a lack of direct, effective communication between inpatient and outpatient providers has been cited as a driving force behind poor care transitions.^6,9

Given the prevalence of postdischarge issues after both pediatric and adult hospitalizations, how should hospitalists proceed? Physicians and health systems should explore approaches to better prepare caregivers, perhaps using models akin to the Seamless Transitions and (Re)admissions Network model of enhanced communication, care coordination, and family engagement.¹⁰ Pediatric hospitalists can prepare children for discharge long before departure by delivering medications to patients prior to discharge,^11,12 providing discharge instructions that are clear and readable,^13,14 as well as utilizing admission-discharge teaching nurses,¹⁵ inpatient care managers,^16,17 and pediatric nurse practitioners¹⁸ to aid transition.

While a variety of interventions show promise in securing a successful transition to home from the hospitalist vantage point, a partnership with primary care physicians (PCPs) in our communities is paramount. Though the evidence linking gaps in primary care after discharge and readmission rates remain elusive, effective partnerships with PCPs are important for ensuring discharge plans are carried out, which may ultimately lead to decreased rates of unanticipated adverse outcomes. Several adult studies note that no single intervention is likely to prevent issues after discharge, but interventions should include high-quality communication with and involvement of community partners.^9,19,20 In practice, providing a high-quality, reliable handoff can be difficult given competing priorities of busy outpatient clinic schedules and inpatient bed capacity concerns, necessitating efficient discharge practices. Some of these challenges are amenable to quality improvement efforts to improve discharge communication.²¹ Innovative ideas include collaborating with PCPs earlier in the admission to design the care plan up front, including PCPs in weekly team meetings for patients with chronic care conditions,^16,17 and using telehealth to communicate with PCPs.

Ensuring a safe transition to home is our responsibility as hospitalists, but the solutions to doing so reliably require multi-fold interventions that build teams within hospitals, innovative outreach to those patients recently discharged to ensure their well-being and mitigate postdischarge issues and broad community programs—including greater access to primary care—to meet our urgent imperative.

Disclosure

The authors declare no conflicts of interest. Dr. Auger’s research is funded by the Agency for Healthcare Research and Quality (1K08HS024735).