Bone and soft tissue manifestations of alveolar echinococcosis

OBJECTIVE

The present study demonstrates the osseous and soft tissue manifestations of alveolar echinococcosis (AE).

PATIENTS

We report on eight patients with AE with bone or soft tissue involvement confirmed at biopsy or needle cytology.

RESULTS

All eight patients showed hepatic involvement. Four exhibited infiltration of the spine as a result of direct spread of the hepatic primary lesion; distant metastases were observed in only three of these patients. Calcifications, which are typical for hepatic manifestations of the disease, were observed in soft tissue in only two of eight cases (25%); we observed no instances of endovesicular daughter cysts.

CONCLUSIONS

AE manifests itself in the vertebral column as a form of spondylitis and in soft tissue presents similar to an abscess. Since in most of these cases spread of the disease per continuitatem from the liver is present, the diagnosis is easily made from the characteristic hepatic findings.

[Clinico-laboratory study of piperacillin/tazobactam in the treatment of patients with would infection]

Piperacillin/tazobactam (P/T) or tazocin was used in the treatment of 40 patients with soft tissue purulent necrotic wounds of various genesis and localization. In the majority of the patients the affection was of recurring nature. P/T was administered in a dose of 4.5 g 3 times a day for 1 to 14 days (mainly for 8 to 10 days) as 30-minute intravenous infusions. The clinical effect of the treatment was stated in 36 patients (90 per cent). In 3 out of 8 patients with diabetes mellitus the treatment failed. In 1 patient the treatment was discontinued after the first dose because of asphyxia and a short-term decrease of the arterial pressure. Among 105 microbial strains isolated from 75 patients 64 were highly susceptible to P/T, 33 were moderately susceptible and 8 were resistant. 76.3 per cent of the isolates produced beta-lactamase, 66.3 per cent of them were susceptible to P/T. 54 gram-positive and gram-negative strains were isolated from 40 patients. 16 out of the 54 strains were isolated as monocultures and the others as associations. After the treatments the pathogen eradication and the pathogen eradication followed by superinfection were stated in 26 patients (66.7 per cent). In 11 patients (28.2 per cent) the pathogen persistence was observed at the background of the clinical improvement in the majority of the patients. The relapses were recorded in 2 patients (5.1 per cent).

Necrotizing soft-tissue infections

OBJECTIVES

To evaluate the causes of necrotizing soft-tissue infections (NSTls) and to determine the outcomes of patients with NSTls.

DESIGN

A restrospective survey of the causes and factors associated with the outcomes.

SETTING

An urban community hospital serving an indigent population.

PATIENTS

A consecutive series of patients with NTSls who were treated between December 11, 1990, and December 28, 1995.

INTERVENTIONS

Patients were treated with operative debridement, intravenous antibiotics, and supportive measures.

MAIN OUTCOME MEASURES

Patient outcomes, causes, the extent of infection, the health status of the patients, causative organisms, and treatment delays.

RESULTS

Forty-five patients with NSTls were identified. Twenty-eight cases (62%) have occurred since January 13, 1994. Parenteral drug abuse, the causative event in 25 cases (56%), accounted for 21 (75%) of the 28 cases identified since January 13, 1994. Skin flora were the primary isolates in 18 (40%) of the cases; 78% of these flora were polymicrobial. Clostridial species were isolated in 8 (18%) of the cases. The overall mortality was 27%. Survivors had less extensive infections and were more stable hemodynamically than nonsurvivors. Patients with necrosis and cellulitis greater than 250 cm2 were less likely to survive than those with less extensive infections. Logistic regression analysis identified the extents of infection, the initial blood pressure, and the initial temperature as independent predictors of outcome in this patient series.

CONCLUSIONS

This is 1 of the largest reported series of patients with NSTls in which parenteral drug abuse is a prevalent causative factor. The proportion of NSTls attributable to the injection of illicit substances has increased notably in the past 2 years and has reached epidemic proportions. Survivors of NSTls had less extensive infections and were more often hemodynamically stable than nonsurvivors. Clostridial species were common in patients with NSTls related to parenteral drug abuse, underscoring the need for awareness of the potential for wound botulism in these patients.

[Subcutaneous and soft tissue involvement associated with AIDS: ultrasonographic aspects. Apropos of 3 cases]

Subcutaneous and soft tissue involvement is frequent in AIDS patients. Although the relevant clinical characteristics have been extensively described in the literature, there has been little work on the radiological features. We therefore report three cases of AIDS with subcutaneous and soft tissue involvement: two cases of pyomyositis and one case of non-Hodgkin's lymphoma. All three were black African men and were aged 22, 28 and 41 years. They were diagnosed as suffering from AIDS and were HIV1 and HIV2 positive. Diagnosis was established using needle puncture and histological (lymphoma) and bacteriological (pyomyositis) examination. We report ultrasound scan findings. The features of the pyomyositis differed from those usually observed in immunocompetent patients. The lymphoma nodules were similar to those described in the literature. They were hypoechoic and homogeneous, with no necrotic center. We believe that subcutaneous and soft tissue infectious involvement, for example pyomyositis, is more frequent in tropical regions than tumors (Kaposi's sarcoma, lymphoma) which are more frequent in Europe. This soft tissue involvement can be considered to be part of the particular picture which is "tropical AIDS".

Infected third branchial cleft cyst: retropharyngeal extension to the superior mediastinum

The presentation of an infected branchial cleft cyst extending into the retropharyngeal space is extremely rare. However, differentiation of this lesion from a simple retropharyngeal abscess is important for surgical planning. The authors describe a 44-year-old woman in whom an infected third branchial cleft cyst was initially misdiagnosed as an abscess and drained surgically. Repeat surgery was necessary when the patient's symptoms recurred several weeks later.

[Use of cefpirome in the treatment of patients with skin and soft tissue infections]

The efficacy of cefpirome was estimated in the treatment of 25 patients: 15 patients with pyo-necrotic wounds of the soft tissue of various genesis and localization and 10 patients with deep thermal burns involving 8 to 40 per cent of the body surface. The clinical and bacteriological efficacies of the treatment in the patients with the wound infection amounted to 100 and 80 per cent respectively. In the patients with the burn infection the respective values were 90 and 80 per cent. The drug tolerance was good. Adverse reactions were observed in 1 patient. Bolus intravenous administration of the drug was preferable by comparison with the injections.

Inflammation: imaging with methoxy poly(ethylene glycol)-poly-L-lysine-DTPA, a long-circulating graft copolymer

PURPOSE

To test whether a nontargeted, long-circulating, synthetic polymer accumulates in areas of inflammation, with high capillary permeability and increased regional blood flow.

MATERIALS AND METHODS

Methoxy poly(ethylene glycol)-poly-L-lysine (PL)-diethylenetriaminepentaacetic acid (MPEG-PL-DTPA) was labeled with technetium-99m for scintigraphy and with gadolinium for magnetic resonance (MR) imaging. Eleven Escherichia coli-infected rats were injected with 1.0 mCi (37 MBq) of Tc-99m-labeled MPEG-PL-DTPA for scintigraphy. Twelve rats underwent 1.5-T MR imaging after intravenous injection of gadolinium-labeled MPEG-PL-DTPA (35 mumol/kg).

RESULTS

Tc-99m-labeled MPEG-PL-DTPA demonstrated nearly eight-fold higher accumulation in infected muscle when compared with normal muscle. Scintigrams and MR images showed areas of inflammation with peak accumulation at 24 hours after injection of Tc-99m- or gadolinium-labeled MPEG-PL-DTPA.

CONCLUSION

Nontargeted, long-circulating, copolymers can efficiently accumulate in sites of inflammation and thus represent an alternative to inflammation-specific agents.

Plantar compartments of the foot: MR appearance in cadavers and diabetic patients

PURPOSE

To demonstrate the plantar compartments of the foot on magnetic resonance (MR) images.

MATERIALS AND METHODS

The plantar compartments of four cadaveric feet underwent MR imaging and were sectioned. Fifteen MR studies in 11 patients with compartmental fluid were evaluated. The epicenter of infection was determined from review of the history, radiographs, and MR images.

RESULTS

In the cadaveric feet, distribution of contrast material conformed to the compartmental anatomic features. MR findings in the specimen correlated exactly with gross findings. All seven feet with infection centered at the second through fourth metatarsal heads demonstrated only central compartment fluid. In seven of eight feet with a more medial or lateral epicenter of infection, fluid was seen in the lateral or medial compartment and in the central compartment. In one foot with a lateral epicenter of infection, fluid was confined to the lateral compartment.

CONCLUSION

MR imaging accurately depicts the compartmental anatomic features of the foot.

Pyoderma fistulans sinifica (fox den disease): a distinctive soft-tissue infection

Pyoderma fistulans sinifica (PFS, also referred to as fox den disease because its multiple fistulae and sinuses resemble the structure of a fox den) is a distinct chronic infectious disease in which epithelialized tracts form within the subdermal fatty tissue. PFS, which has not been previously described in the English-language literature, must be differentiated from hidradenitis suppurativa, pilonidal sinus, and perianal fistula. The fistulous tracts of PFS are always lined by stratified squamous-cell epithelium but, unlike those of hidradenitis, reach deep into the subcutaneous fat, run epifascially for long distances, and have no relation to skin appendices. We report on 10 men (mean age +/- SD, 36 +/- 5 years) with PFS (mean duration +/- SD, 11 +/- 7 years). Bacterial cultures of affected tissue from these patients yielded a total of 14 facultative and 31 obligate anaerobic species. Treatment consisted of wide en-bloc excision down to the fascia, including all fistulae. Antibiotic therapy temporarily reduced purulent discharge but did not eradicate the infection. Two patients who underwent fistulotomy without wide en-bloc excision developed recurrences.

Fine-needle aspiration biopsy of cervicofacial masses in children

OBJECTIVE

To show the usefulness of fine-needle aspiration biopsy (FNAB) in the diagnosis of cervicofacial masses in children.

DESIGN

Case series.

SETTING

Pediatric otolaryngology referral center, ambulatory and hospitalized patients.

PATIENTS

Seventeen pediatric (age, < 18 years) patients with cervicofacial masses.

INTERVENTION

Fine-needle aspiration biopsy.

OUTCOME MEASURES

Cytologic diagnosis, resolution of mass, and need for further surgical diagnosis or treatment.

RESULTS

Following FNAB, 10 patients underwent open surgery; in seven, the surgery was indicated based on FNAB diagnosis; in three, surgery provided diagnoses where FNAB was insufficient. Based on FNAB data, seven patients were observed without surgery.

CONCLUSIONS

Fine-needle aspiration biopsy is a useful early step in diagnosing cervicofacial masses in children.

Low-field MR imaging for the assessment of therapy response in musculoskeletal infections

Fifty-one patients with musculoskeletal infection were imaged by repeated MR imaging at ultra low-field and low-field strength. Soft-tissue infection, osteomyelitis, septic arthritis, and spondylitis were studied. The MR finding was scored according to the signal intensity (SI) on T2-weighted images (T2WI), and correlated with the values of serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and peripheral white blood cell (WBC) count. There was a positive correlation between the MR score and both CRP and ESR, but no correlation between MR score and WBC. The MR score between the follow-up studies decreased significantly in accordance with clinical reconstitution. The MR finding according to the SI on T2WIs corresponded better to disease activity than did the CRP or ESR.

Primary soft-tissue nocardiosis

A 20-year-old Latin American man presented with a 4 1/2-year history of a left infrapatellar mass with multiple draining sinuses. Multiple courses of oral antibiotics before referral were unsuccessful in eradicating the mass. Microscopic examination of material obtained by punch, core needle, and incisional biopsies demonstrated nonspecific acute and chronic inflammation. Surgical resection demonstrated an inflammatory mass with multiple abscess cavities. Intraoperative cultures grew Nocardia asteroides. The infection was successfully treated with a prolonged course of a trimethoprim-sulfamethoxazole.

Protothecosis in an HIV-positive patient

This is the first report of localized tendosynovial human protothecosis in an HIV-positive host. The lesion appeared as a nodule in the extensor face of the thumb. A simple excision was performed, and histology confirmed numerous granulomas, some with central fibrinoid necrosis. Enormous numbers of prototheca were found in periodic acid-Schiff and Gömöri methenamine silver strains, evidencing endosporulation with diagnostic morula- or daisy-like sporangia. The presence of prototheca species was confirmed by direct immunofluorescence with the specific conjugate. The cellular response estimated by the relative number of polymorphonuclear leukocytes, lymphocytes, and plasma cells was minimal, although granuloma formation was unaffected. The infective agents were found either extracellular or harbored by macrophages and giant cells.

[Cryosurgery in the treatment of suppurative diseases of the soft tissues in children]

The method of cryosurgical debridement in purulent diseases of the soft tissues in children is simple, effective, shortens the time for treatment by 23.4%, and has practically no contraindications. Cryosurgical debridement of the purulent focus accelerates rejection of the necrotic tissues, increases the flow of blood in the region of the wound, and stimulates the regeneration processes. The cryogenic effect reduces the resistance of the microflora to antibiotics without causing an essential influence on the content of microbes in the wound, and also has a favorable effect on the functional activity of the cells of the inflammation.

[Laser and ultrasonic therapy in the treatment of acute purulent diseases of the soft tissues in children]

The article analyses the results of active treatment of pyoinflammatory diseases in 138 children by means of CO2-laser and ultrasonic cavitation. The control group was formed of 145 children who were treated by the commonly applied methods. The efficacy of surgical debridement was appraised according to the number of bacteria per g of tissues. Various methods of opening and treatment of the purulent cavity are compared. The differentiated use of the laser beam and ultrasonic cavitation depending on the character of the pathological process is substantiated. The schemes of ultrasonic cavitation with the use of various solutions and their combination depending on the phase of the wound process are shown. A combination of laser cleansing and ultrasonic cavitation is most rational. Complete epithelialization of the wound occurs 5-6 days earlier than in the control group.