[Primary giant hydatid cyst in the thigh]

Human hydatid cyst is a zoonotic infection that usually attacks visceral organs. Primary soft tissue involvement is very rare, causing a diagnostic challenge. Primary soft tissue hydatid cyst was encountered in an 83-year-old man, which presented as a giant lesion in the posterior aspect of the right thigh, extending from the gluteal region proximally to the popliteal region distally. A multiloculated cystic mass was completely resected and histopathological examination confirmed the preoperative diagnosis. No local or systemic complications occurred postoperatively. The patient recovered fully at the end of postoperative 12 months.

Necrotising infections of soft tissues--a clinical profile

OBJECTIVE

To study the clinical profile and outcome of patients with necrotising soft-tissue infections.

DESIGN

Prospective study.

SETTING

Teaching hospital, India.

SUBJECTS

75 patients (54 male and 21 female), mean age 40 years (range 8 months-85 years).

INTERVENTIONS

Patients were uniformly managed by initial resuscitation, debridement, topical wound care, systemic antibiotics, and enteral hyperalimentation.

MAIN OUTCOME MEASURES

Morbidity and mortality.

RESULTS

Aetiology of the infections included major and minor trauma, minor skin infections and postoperative infections. 22 patients were diabetic. The extremities were involved in 57 patients, the trunk in 26 and the perineum in 21. 68 presented with local tenderness (91%), 74 with oedema (99%), 54 with erythema (72%), 55 with ulceration (73%), and 54 with a purulent or serous discharge (72%). beta-haemolytic streptococci were isolated from only 10 patients. Staphylococcus aureus was the most common bacteria isolated (n = 30, 46%) followed by Bacteroides fragilis and anaerobic cocci (n = 22, 34% each). Cultures grew fungi in 9 patients. 20 patients died giving a mortality of 27%. Jaundice and serum albumin were the only factors to have a significant influence on mortality.

CONCLUSIONS

Necrotising soft tissue infections are potentially fatal. Early recognition and prompt aggressive debridement are the keys to successful management.

Necrotizing soft tissue infections of the head and neck: case reports and literature review

A small but nevertheless important part of a surgeon's experience comprises necrotizing soft tissue infections of the head and neck. The purpose of this report is to heighten awareness of necrotizing soft tissue infections in any patient with an infection of the head and neck. The article also outlines an appropriate management strategy for use in the treatment of patients with this potentially fatal condition. Prompt diagnosis and early radical surgical debridement are significant factors in avoiding a fatal outcome in these patients. This article reviews the literature on necrotizing soft tissue infections of the head and neck and presents cases from our recent experience.

A Case of Cervical Necrotizing Soft Tissue Infection

We treated a 62-year-old woman with a cervical necrotizing soft tissue infection of the Streptococcus milleri group. Numerous spot gas images were recognized from the right pharynx to the neck in CT at initial diagnosis, but we chose conservative treatment because abscess findings were not clear. The inflammation improved temporarily, but we operated through an outside incision because symptoms recurred and cervical skin became necrotic after one week. Inside, the fascia were necrotic and an abscess extended from the precordia to the left upper arm and the right axillary region. The cervical skin defect was restored in due course in about 2 months and cured without mediastinitis or sepsis developing. The S. milleri group was detected in pus. A cervical necrotizing soft tissue infection does not form an abscess mainly in one space as does a normal deep neck infection and invades fascia space rapidly and widely. We took this disease into consideration and had to intervene surgical rather soon. A review of this case and the literature indicates that the S. milleri group may have become an important pathogen in cervical necrotizing soft tissue infection.

Clostridium novyi type A infection: a sporadic fatal case

Infection with type A Clostridium novyi is rare. We report the case of a previously healthy 31-y-old woman with no known risk factors who died suddenly with a necrotizing soft tissue infection. We compare this case with a simultaneous outbreak of this infection amongst Scottish IDUs (injecting drug users).

[Role of phagocytosis activation in the mechanism of therapeutic effect of medical ozone in patients with sluggish purulent inflammations of maxillofacial soft tissues]

Sixty-three patients with local sluggish suppurative inflammations of maxillofacial soft tissues were examined. Medical ozone was added to the treatment protocols of 30 of these patients. Before treatment peripheral blood leukocyte phagocytic activity was decreased in 54 patients, which corresponded to clinical form of a sluggish inflammation. Traditional therapy did not appreciably change the level of phagocytosis. Addition of medical ozone exposure to therapy promoted normalization of leukocyte phagocytic activity and accelerated liquidation of inflammation.

[Ozone therapy in treatment of local sluggish suppurative inflammation of maxillofacial soft tissues]

Combined local and general ozone therapy was used in 30 patients with local sluggish pyoinflammatory diseases of the maxillofacial soft tissues. The results were compared to those in 33 patients administered no ozone therapy. Ozone therapy decreased the duration of treatment more than 2-fold due to antibacterial effect and stimulation of nonspecific and immunological reactivity. Lack of obvious contraindications and selective activity and universal immunocorrective effect recommend ozone therapy for wide use in this patient population irrespective of the type of inflammatory reaction.

Epidemiology and microbiology of cellulitis and bacterial soft tissue infection during HIV disease: a 10-year survey

BACKGROUND

Cellulitis and soft tissue infection are underestimated complications of HIV disease.

PATIENTS AND METHODS

Sixty-seven bacteriologically proven consecutive episodes were identified among 2221 HIV-infected patients hospitalized in a 10-year period, and assessed according to several epidemiological, microbiological and clinical variables.

RESULTS

Staphylococcus aureus was the most frequently cultured pathogen (50% of 92 isolates), followed by Pseudomonas spp., Escherichia coli and Streptococcus pyogenes; a polymicrobial infection was present in 38.1% of episodes. Drug addiction (p < 0.003) and male gender (p < 0.04) were significantly associated with the occurrence of these complications, which were community-acquired in 83.6% of cases. While a remarkable variation in the severity of underlying immunodeficiency was shown, hematogenous dissemination occurred in 25.4% of episodes, and proved significantly related to a low CD4+ lymphocyte count, and neutropenia. A 21.7% methicillin-resistance rate was shown among S. aureus isolates. All episodes were favorably treated in 5-16 days, in over 60% of cases with associated beta-lactam-aminglycoside antibiotics; a recurrence of staphylococcal cellulitis occurred in four patients only.

CONCLUSION

Skin and soft tissue infections are continuing causes of morbidity in HIV-infected patients, even in the highly active antiretroviral therapy era.

[Streptococcus group A infections of skin, soft tissue and blood]

BACKGROUND

Group A streptococcus is one of the most common bacterial pathogens causing infections in tissue and organs, most frequently throat and skin. Since the late 1980s there have been reports from Scandinavia and many other countries documenting a resurgence of highly invasive infections such as puerperal fever, necrotizing fasciitis, myositis and sepsis.

MATERIAL AND METHODS

On the basis of relevant studies and reviews and a clinical study of 61 patients between 1992 and 1999 with necrotizing fasciitis and myositis at Haukeland University Hospital, Bergen, Norway, we present an overview of the prevalence, pathogenesis, clinical features and treatment of group A streptococcal infections in skin, soft tissue and blood.

RESULTS AND INTERPRETATION

The reason for the increase in severe group A streptococcal infections is unclear. The clinical features depend on the level of infection (superficial skin, subcutis, fascia and muscle): the deeper the initial infection, the more frequent development of bacteraemia and life-threatening disease. Serious infections are associated with shock and multiorgan failure, i.e. streptococcal toxic shock syndrome. Early surgical debridement is essential in necrotizing fasciitis and myositis. Penicillin is still the drug of choice for milder infections. The addition of clindamycin is recommended in cases of more invasive infection.

Invasive streptococcal infection of the periorbita and forehead

Recent epidemiological reports suggest an increased frequency of invasive streptococcal infections linked to the appearance of a dominant group A Streptococcus serotype. Necrotizing streptococcal infections involving the skin and soft tissues of the face are uncommon. This case demonstrates the aggressive and invasive nature of these infections. The patient presented with symptoms of angioedema and was treated with corticosteroids. Her condition worsened and plastic surgery was consulted. There was extensive necrosis of the periorbital and forehead soft tissue, requiring extensive debridement to control the invasive process. Multiple reconstructive procedures were performed to close the defects and to preserve function of the facial muscles and eyelids. The literature indicates less than 50 reported cases of necrotizing streptococcal infections limited to the periorbita. This case reflects the importance of rapid diagnosis, and emphasizes the need for prompt and appropriate surgical treatment.

Unexplained deaths among injection drug users: a case of probable Clostridium myonecrosis

A series of unexplained deaths associated with soft-tissue inflammation and severe systemic sepsis was reported among injection drug users (IDUs) in the United Kingdom and the Republic of Ireland in 2000. Health Canada has identified one reported fatality in an IDU that matched the case definition. Although the cause of the epidemic in the UK and Ireland is not fully understood, contributing factors include injecting into muscle or beneath the skin, rather than directly into a vein, and the use of acid to dissolve the heroin. This single Canadian case is considered to be a sporadic event that occurs at a low background rate among IDUs. These cases serve to remind primary health care providers to be vigilant in cases of soft-tissue infection among IDUs and not to underestimate the potential severity of the situation.

Cutaneous nocardiosis of the chest wall and pleura--10-year consequences of a hand actinomycetoma

We report an unusual case of primary cutaneous nocardiosis due to Nocardia otitidiscaviarum presenting first as a mycetoma of the right hand and wrist. The patient refused treatment and was lost to follow-up until he showed up 10 years later with numerous discharging large sinuses and abscesses on the upper right quadrant of the chest wall and in the right armpit. Roentgenograms revealed pleural masses. Histology was in keeping with the diagnosis of mycetoma. Treatment with amikacin, rifampicin and co-trimaxole proved to be successful.

Soft tissue infection caused by Kingella kingae in a child

During the last years an increasing number of reports concerning Kingella kingae infections in children has been published. Most cases were osteoarticular infections. The authors report the clinical and laboratory findings from a 3-year-old child with a presternal soft tissue infection due to K kingae. After surgical excochleation and antibiotic treatment there was an uneventful recovery. J Pediatr Surg 36:946-947.

Rhinophycomycosis

Rhinophycomycosis, a subcutaneous fungal infection, is less uncommon than many other frequently cited granulomatous lesions of the paranasal sinuses. Four illustrative cases are presented with their characteristic clinical, radiological and histopathological features. The initial origin of the swelling was always in the region of the nasal vestibule and ala. The therapeutic response to potassium iodide, ketaconazole and fluconazole was dramatic and sustained.

[Treatment of purulent-inflammatory complications of the soft tissues wounds in elderly and senile patients]

Experience of treatment of elderly and senile patients with purulent infection of the soft tissues wounds was summarized. For raising of the therapeutic effect of the local treatment the introduction of new combined medicinal forms, composition of which was scientifically substantiated according to the wound process pathogenesis with special attention to its phase and character of microflora (kind of microorganism and its sensitivity to antimicrobic agents), is perspective.

[Necrotizing soft tissue infections as the only clinical manifestation of retroperitoneal colonic perforation]

Necrotizing infections are rapidly progressive potentially lethal bacterial diseases of the soft tissues. In based on the widely varying levels of soft tissues affected and the variety of the microflora, two types of necrotizing soft tissue infections need to be delineated: pure Chlostridial myonecrosis and other necrotizing soft tissue infections (NSTI). From an etiopathogenetic point of view NSTI can be secondary to perianal or urogenital abscesses, traumatic lesions, wound infections, trophic or decubitus ulcers, oral cavity abscesses; only in a limited number of cases their origin can be idiopathic. Exceptionally it can happen that a NSTI could represent the only clinical manifestation of a retroperitoneal colic perforation. The Authors report their experience regarding two clinical cases recently observed. The first patient, who previously underwent colic resection for sigmoid carcinoma and adjuvant chemotherapy, had developed as only clinical manifestation of retroperitoneal anastomotic fistula a necrotizing infection at the root of the hip, extended along the whole leg. The second patient, with diverticular perforated disease, had developed rhe necrotizing infection in the lumbar region and in the perirenal tissues. Here will be discussed the sensitivity of the possible diagnostic investigative techniques and the therapeutical strategies that brought both the patients to a complete recovery.

Assessment of tissue viability in complex extremity injuries: utility of the pyrophosphate nuclear scan

BACKGROUND

Extensive extremity injuries often require difficult decisions regarding the necessity for amputation or radical debridement. During the past decade, we have used technetium-99 pyrophosphate (PyP) scanning as an adjunct in this setting. This study was performed to assess the accuracy of PyP scan in predicting the need for amputation in relation to clinical, operative, and pathologic findings.

METHODS

Review of our computerized registry identified 11 patients (10 men, age 36.1 +/- 14.9 years) admitted from 1990 to 1999 who underwent PyP scan. Using operative and pathologic findings, accuracy of the PyP scan was graded as supporting or refuting the clinical assessment of the need for amputation.

RESULTS

Eight patients suffered high-voltage electrical injuries, one had severe frostbite, and two suffered soft-tissue infections. In most cases, PyP scan showed clear demarcation of viable and nonviable tissue, verifying the need for amputation (positive); those that demonstrated viable distal tissues confirmed at operation were considered negative. PyP scan had a sensitivity of 94%, a specificity of 100%, and an accuracy of 96% in this setting.

CONCLUSION

Technetium-99 PyP scanning is a useful adjunct in predicting the need for amputation in extremities damaged by electrical injury, frostbite, or invasive infection. In addition, by providing an objective "picture" of extremity perfusion, PyP scans can be helpful in convincing patients of the need for amputation.

Quantitative swab culture versus tissue biopsy: a comparison in chronic wounds

Soft tissue infection present a significant obstacle to the healing of chronic wounds. Historically, the gold standard for determining wound bacterial bioburden has been the quantitative tissue biopsy. Nevertheless, tissue biopsies are not universally used in today's healthcare setting. Likely reasons include damage to healing tissue, the lack of facilities to process tissue biopsies, significant pain in sensate soft tissue, and increased expense with this modality. More recently, quantitative tissue swab culture has been suggested as a means to determine the wound bioburden. The authors prospectively studied 38 patients with chronic wounds of various etiologies to evaluate the correlation between quantitative wound biopsy and swab culture. Of the 38 biopsies performed, 74% indicated infection. Simultaneous swab culture of these 28 biopsies indicated infection in 22 of the 28 cases for a correlation of 79%. The authors concluded that quantitative swab culture provides a valuable adjunct in the management of chronic wounds.

Characterization of a mouse-passaged, highly encapsulated variant of group A streptococcus in in vitro and in vivo studies

JRS4(HE), a highly encapsulated, mouse-passaged variant of group A streptococcal strain JRS4, was characterized. The mucoid phenotype of JRS4(HE) was preserved after extensive passage in vitro. The level and size of csrRS transcript in JRS4(HE) was similar to that of JRS4, yet JRS4(HE) expressed high levels of has and sagA and exhibited an increased activity of streptolysin S. These findings indicate that the CsrRS repressor system was inactive in JRS4(HE). JRS4(HE) adhered to HEp-2 cells at the stationary phase but did not internalize these cells. At midlogarithmic phase, JRS4(HE) neither adhered to nor internalized cells, because of an increased amount of hyaluronic acid. Mice injected subcutaneously with JRS4(HE) developed large, deep necrotic lesions. In contrast, mice challenged with JRS4 developed small, superficial lesions. Despite the use of a high inoculum, mice challenged with JRS4(HE) did not develop a lethal bacteremic infection. It is concluded that inactivation of CsrRS in vivo is insufficient to cause a spreading necrotic disease.

[Pathomorphological aspects of the inflammatory process in soft tissues during the ozone application in the experiment]

In 35 white rats of Wistar line abscess of soft tissues was modelled. In animals of principle group influence of ozone-oxygenous gaseous mixture with concentration of ozone 0.1 mg/m3 times daily during 10 min were applied. While applicating ozone were noted reduction of exudative reaction and more rapid change of inflammatory phase, more early formation and maturation capsule around necrotic zone, than in control group, that promoted effective delineation of damage focus and enhancement of the inflammatory and dystrophic changes severity in tissues surrounding abscess.