Multiple erythematous nodules and ecthyma gangrenosum as a manifestation of Pseudomonas aeruginosa sepsis in a previously healthy infant

Pseudomonas aeruginosa septicemia is rare in healthy infants and children. Also not common, dermatologic manifestations such as ecthyma gangrenosum and indurated erythematous nodular lesions may be the first signs of pseudomonas infection, or may appear later in the course of the disease. Peripheral facial paralysis and mastoiditis are also rare and serious complications of acute otitis media caused by P. aeruginosa. We report a previously healthy 6-month-old boy who had an uncommon presentation and rare complications during the course of P. aeruginosa sepsis.

Gastro-colonic anastomosis--a viable option in extensive small bowel infarction

INTRODUCTION

We have previously presented a patient with massive small and large bowel infarction and demonstrated that even with only a few inches of remaining small bowel an almost normal life-style and diet is possible.

PATIENT

Recently, we have looked after a young and otherwise fit female patient who suffered mesenteric venous gangrene of the whole small bowel from the Ligament of Treitz to the caecum. In order to achieve gastro-intestinal continuity and to avoid the torrential fluid loss associated with high fistula, an anastomosis between the stomach and the transverse colon was formed.

RESULTS

We are surprised to find that despite the extensive resection our patient maintains a good quality of life and is able to look after her young family.

Intestinal Ischemia-Reperfusion Injury Does Not Lead to Acute Central Nervous System Damage

BACKGROUND

The detrimental effects of intestinal ischemia reperfusion (IIR) injury on secondary organs including the liver, lungs, heart, and kidney have been widely investigated in animal models. However, the effect of IIR on the central nervous system (CNS) is largely unknown. We investigated the effect of IIR on the CNS as it may be of clinical relevance to patients at high risk of neurological injury.

MATERIALS AND METHODS

Adult male rats underwent IIR (60 min superior mesenteric artery occlusion followed by 120 min reperfusion, n = 7) or sham operation (n = 6) under anesthesia. Following the procedure, the cerebral hemispheres were removed for histological assessment and measurement of N-acetyl-aspartate (NAA), a marker of neuronal damage, by HPLC. Blood was taken for determination of plasma S100B concentration, a measure of glial cell damage by ELISA. Data are median (range).

RESULTS

Cerebral tissue from all animals from both groups was macroscopically and microscopically normal with no evidence of inflammation. NAA in brain homogenate was similar in the IIR group (0.2 [0.1-0.32] nmol/mg protein) and sham-operated group (0.19 [0.12-0.34], P = 0.83). Plasma S100B levels were higher in the IIR group compared to sham-operated animals but this difference was not statistically significant (1.13 [0.24-7.26] versus 0.55 [0.23-2.84] mug/l, P = 0.18).

CONCLUSIONS

In this model, IIR injury did not produce histological CNS changes nor biochemical changes suggestive of neuronal damage. Further work is required to elucidate any functional effect of IIR injury on the CNS.

Mycotic dermatitis with digital gangrene and osteomyelitis, and protozoal intestinal parasitism in Marlborough green geckos (Naultinus manukanus)

CASE HISTORY

Thirty adult Marlborough green geckos (Naultinus manukanus) were collected from Stephens Island and held over winter, prior to their translocation. Five adult geckos developed skin lesions after husbandry changes affected the humidity of their enclosures. Two geckos underwent ecdysis and recovered. One animal died and two others progressively worsened and were presented for treatment.

CLINICAL AND PATHOLOGICAL FINDINGS

The geckos were in poor body condition and had multiple black powdery lesions and solitary raised white nodules on their skin. Both geckos died despite topical and supportive treatment. Histopathology showed the skin nodules contained branching non-septate hyphae infiltrating necrotic epidermal tissue, and associated dermal inflammation. There was necrosis of several digits and mycotic osteomyelitis. Mucor ramosissimus was cultured from skin biopsies from each animal. Large numbers of motile protozoa, resembling Trichomonas, and another unidentifiable, were recovered from fresh faecal smears, and Nyctotherus sp protozoa were present in the lumen of the intestine of one animal post mortem.

DIAGNOSIS

Mycotic dermatitis with digital gangrene and osteomyelitis due to Mucor ramosissimus, and enteric protozoal parasitism with Trichomonas sp and Nyctotherus sp.

CLINICAL RELEVANCE

The clinical course and pathological findings of mycotic dermatitis in two Marlborough green geckos involved in a wildlife translocation in New Zealand are reported, and also the first record of the Marlborough green gecko as a host for the enteric protozoa Trichomonas sp and Nyctotherus sp.

[Gangrene of Meckel's diverticulum in strangulated left inguinal hernia]

We report a case of a 57-year-old woman admitted for abdominal pain and a not reducible mass in left inguino-abdominal region. With a diagnosis of strangulated inguinal hernia, the patient underwent urgent surgery. The surgical exploration showed a gangrenous intestinal loop with a Meckel's necrotic diverticulum. A small bowel resection (20 cm) was performed. The post-operative course was uneventful. This seems the first case reported in the literature of woman with a Meckel's diverticulum involved in a strangulated left inguinal hernia.

Arterial occlusion in systemic lupus erythematosus: a good prognostic sign?

Arterial occlusion with subsequent amputation of extremities is a rare manifestation of systemic lupus erythematosus (SLE). It may be caused by local arteritis and/or thrombosis. We describe the clinical and laboratory manifestations and treatment administered to six SLE patients who developed peripheral arterial necrosis necessitating amputation of extremities secondary to the arterial occlusion. All patients were female, with ages ranging from 16 to 65 years. Arterial occlusion took place in the initial months of disease (median: 7 months). Only one of five patients tested for antiphospholipid antibodies had these antibodies who also had vasculitis and thrombosis in a histopathological study. Most patients presented a very benign outcome after the amputation of extremities and stayed in remission for several years. The satisfactory outcome of most patients after the vascular phenomenon allows us to consider the possibility that such a complication could be, for unknown reasons, a marker for good prognosis in SLE or, alternatively, that the aggressive therapy administrated for patients with this complication at the beginning of the disease could recover the balance of the immune system, avoiding future relapses.

Spontaneous fulminant gangrene of distal colon and rectum

A case of a young female is reported who presented with acute abdomen and peritonitis. Emergency laparotomy revealed fulminant gangrene of descending colon and upper third of rectum. Two-stage procedure was carried out as transverse colostomy and subsequent colorectal anastomosis two months later.

Small bowel volvulus leading to gangrene and short bowel syndrome

A young man was operated for acute abdomen. Laparotomy revealed small bowel diverticulosis with very short mesentery leading to volvulus of near total small bowel. Resection and end to end anastomosis was performed. Patient ended up with short bowel syndrome.

[Incidence of pyo-necrotic complications of the diabetic foot syndrome and preferences of specialized care]

Total retrospective clinical-social investigation of 2431 patients with pyo-necrotic complications of the diabetic foot syndrome (DFS) has revealed a considerably increased incidence of pyo-necrotic complications of DFS, mainly at the expense of patients with type II diabetes mellitus. Most of these patients (87.8%) are elderly and senile patients with a middle or severe degree of diabetes (98.2%) and signs of subcompensation or decompensation (87.2%). In 98.0% of the patients there were coexisting diseases. 87.9% of the patients were urgently admitted to hospital with acute pyo-inflammatory processes. A comparison of the results has shown that treatment and interdisciplinary observation in specialized institutions allowed to reduce lethality and number of high amputations more than two times.

[Specific surgical strategy for gangrene of both lower extremities]

At admission of patients with gangrenes of both lower extremities the surgical strategy was not determined. The author has also failed to find corresponding recommendations in the available literature. On the basis of his clinical experiences with 12 patients who underwent big amputation of lower extremities for bilateral gangrene, the author proposes the surgical methods. The optimal variant is considered to be a by turns amputation with the interamputation period being determined by a relative stabilization of the life-support systems.

MR imaging of the normal appendix and acute appendicitis

PURPOSE

To describe the MR appearance of the normal appendix and the MR imaging characteristics of acute appendicitis with correlation to pathological severity.

MATERIALS AND METHODS

A total of 20 volunteers participated in this study to demonstrate normal appendices by MR imaging. A total of 37 consecutive patients with clinically diagnosed acute appendicitis were also scanned. T1-weighted (T1WI) spin-echo images, T2-weighted (T2WI) fast spin-echo, and fat-suppressed spectral presaturation inversion recovery T2-weighted (T2SPIR) fast spin-echo images were obtained. The MR criteria for considering acute appendicitis were as follows: 1) thickening of the appendiceal wall with high intensity on T2WI or T2SPIR; 2) dilated lumen filled with high intensity material on T2WI or T2SPIR; and 3) increased intensity of periappendiceal tissue on T2WI or T2SPIR.

RESULTS

The visibility of a normal appendix on MR imaging was 90% (18/20). It appeared as a cord-like structure of medium intensity without fluid collection in the lumen. A total of 30 cases with clinically diagnosed acute appendicitis had positive MR findings and all except one were pathologically proven. The one had cecal diverticulitis. These cases demonstrated filled lumen, with a hypointense wall on T1WI and slightly hyperintense on T2WI or T2SPIR. MR findings correlated well with pathological severity, especially a thicker wall, periappendiceal high intensity, and ascites were useful for suspecting severe appendicitis.

CONCLUSION

Correct diagnosis of acute appendicitis was obtained with MRI, and correlated well with its pathological severity. MRI is a powerful alternative for diagnosing acute appendicitis especially for the patients in whom the radiation is major concern.

Massive deep venous thrombosis and venous gangrene in a 29-year-old case: metastatic epidermoid carcinoma with an unknown primary

Cancer-associated venous thromboembolism is a severe form of paraneoplastic syndrome. It rarely leads to venous gangrene. We report a case who presented with multiple deep venous thrombosis and venous gangrene of the lower extremity. During the follow-up period, the patient developed bilateral cervical and right supraclavicular lymphadenopathies. The fine needle aspiration of the lymph nodes revealed metastatic epidermoid carcinoma of an unknown primary. Thrombotic manifestations may complicate the clinicopathological course of malignancies.

An unusual presentation of group B streptococcal sepsis

This paper describes the devastating outcome of a neonate who presented with severe late onset group B beta-haemolytic streptococcal (GBS) disease. There were extensive infarcts of the brain and gangrene of the toes. The purpose of this report is to alert healthcare workers of the unusual presentation and that fatal late onset group B beta-haemolytic streptococcal disease may occur despite early and effective management.

Lower limb necrosis after use of the anterolateral thigh free flap: is preoperative angiography indicated?

The large and potentially sensate skin territory, the reliability, and the versatility of the anterolateral thigh flap have led to its use for the reconstruction of soft-tissue defects of the head and neck region, extremities, and trunk. Most authors describe the functional disturbances in the donor site as minimal and, to date, no cases of circulatory disturbance of the lower limb as a result of anterolateral thigh flap transplantation have been described. The authors report a patient with partial necrosis of the foot and calf caused by the interruption of the descending branch of the lateral circumflex femoral artery, which acted as a critical collateral for the obstructed superficial femoral artery. Based on their observations of this patient, the authors recommend preoperative angiography of the donor leg in patients in whom palpable popliteal pulsations are lacking. Intraoperatively, the chances of postoperative circulatory disturbance of the lower leg can be decreased by observation of the lower leg circulation after clamping of the flap's pedicle. Immediate arterial reconstruction using a venous graft is to be considered in cases in which the adequacy of circulation is debatable.

Capnocytophaga canimorsus Sepsis with Purpura Fulminans and Symmetrical Gangrene following a Dog Bite in a Shelter Employee

The authors describe a fatal case of purpura fulminans with symmetrical peripheral gangrene and sepsis caused by Capnocytophaga canimorsus in a 45-year-old, previously healthy woman who was bitten by a dog at an animal shelter where she was employed. Absent in this patient were the usual risk factors, including immunosuppression, alcohol abuse, corticosteroid therapy, and splenectomy. The patient's presentation to the emergency room late in the course of the infection probably effected her death. C canimorsus should be strongly suspected in any case of septicemia following a dog bite. Prompt therapy may influence the potentially fatal course of systemic infection. Employees and/or volunteers who work in animal shelters should be cognizant of the potential risks of a dog or cat bite and follow recommended procedures when such an incident occurs.

Cancrum oris

A malnourished 9-year-old boy presented with an infection in the buccal space that developed into cancrum oris during the course of treatment.