Bacterial etiology of empyema thoracis and parapneumonic pleural effusion in Thai children aged less than 16 years

This study aimed to identify the bacterial etiology of empyema thoracis or parapneumonic pleural effusions in Thai children, with a focus on pneumococcus. This hospital-based, descriptive study included children aged < or = 16 years, diagnosed with empyema thoracis or parapneumonic pleural effusion, from whom a pleural fluid (PF) sample was taken between January 2008 and November 2009. PF and blood samples were cultured and PF samples were also tested by polymerase chain reaction (PCR) to assess whether evidence of an infection might be identified among culture-negative samples. Serotyping of Streptococcus pneumoniae-positive samples was performed by molecular techniques and Quellung reaction. In this study, 29 children with empyema thoracis and 42 children with parapneumonic pleural effusion were enrolled. Potentially pathogenic bacteria were cultured in 13/71 samples at local or central laboratories; the most common bacteria were Staphylococcus aureus (8 children) and S. pneumoniae (2 children). Molecular techniques detected one or more targeted respiratory pathogens in 18/71 PF samples. S. pneumoniae and Haemophilus influenzae were identified by PCR in 13 and 6 children, respectively; PCR for S. aureus was not performed. The pneumococcal serotypes identified were 1, 3, 5, 6A/B, 9A/V, 14, 15A, 19F and 23A. This study shows that among Thai children with empyema thoracis and parapneumonic pleural effusions, S. aureus and S. pneumoniae were the most common pathogens identified by culture and PCR, respectively. These findings confirmed that molecular techniques are more sensitive for identification of S. pneumoniae and H. influenzae and enhance detection of important bacterial causes of empyema.

A thoracic mass infiltrating the chest wall

A case of thoracic mass infiltrating the chest wall mimicking a pulmonary invasive neoplasm is reported. Differential diagnosis and characteristic radiological and histological imaging had a decisive role in the case management. Actinomycosis is caused by a gram-positive, filamentous, microaerophilic bacteria. About 15% of the infections caused by Actinomyces involve the thorax. If not promptly diagnosed and treated thoracic actinomycosis may determine contiguous and systemic involvement. Actinomycosis is an anaerobic-to-microaerophilic bacteria and direct identification and isolation are difficult to obtain. In depth discussion diagnostic and therapeutic features are described in this report.

Spontaneous Subscapular Abscess: A Rare Surgical Condition

Subscapular abscess is a rare clinical problem. Herein we describe a young male patient who presented with a subscapular abscess and was managed successfully with surgical drainage and debridement of the cavity.

Pott's disease in a young child

A 16-month-old emaciated, immunized child presented with low-grade fever and progressive kyphosis with a right sided para-vertebral abscess for 9 months. During this period of illness the child had marked loss of appetite and progressive weight loss. There was history of contact with sputum smear positive father. A gibbus was present at thoraco-lumbar region with a cold abscess at the right side of the gibbus and signs of upper motor neuron lesion were found on lower limb examination. Diagnosis was supported by relevant investigations including MRI of dorsolumbar spine and treatment was started beforehand with anti-tubercular drugs. The paravertebral abscess was drained several times and antibiotics were used depending upon the results of microbiological study. At the same time the patient was advised to wear a modified chest brace for immobilization and the management for severe malnutrition was also started accordingly. There was significant clinical improvement observed within one month of starting treatment.

Relevance of group Milleri streptococci in thoracic surgery: a clinical update

Group Milleri streptococci (GMS), a heterogeneous group of streptococci, are associated with purulent infections. This study was a retrospective analysis of all consecutive thoracic infections of GMS between 2001 and 2004. Of 246 surgical GMS infections, thoracic infections accounted for 4.5 per cent, including 10 pleural infections (eight empyemas and two infected pleural effusions) and one mediastinal infection. The etiology of pleural infection was parapneumonic (7), second to esophageal perforation (1), liver transplantation (1), and liver resection (1). Polymicrobial infections were present in 64 per cent. All patients underwent removal of the infected masses, including drainage (3), thoracoscopic decortication (5), thoracotomy with debridement (2), and incision with drainage (1). The case fatality rate was 9 per cent (there was one patient with congestive heart disease unfit to undergo surgical empyema evacuation) and the recurrence rate was 27.3 per cent (three patients). Combined antibiotic/surgical treatment was successful in all other cases. GMS isolates were susceptible to clindamycin and all beta-lactam antibiotics except ceftazidime, but were resistant to aminoglycosides. If found intrathoracically, GMS frequently progress to severe empyema. Therefore, timely removal of pleural collection by percutaneous drainage or surgical intervention seems indicated. If surgery is required, thoracoscopic decortication may be the preferred approach.

A case of chronic chest wall sinus

A 17-year-old Muslim female presented with a swelling over the chest wall underneath her left breast. The swelling was aspirated and the cytology report of the aspirated material showed it to be of pyogenic origin. An incision and drainage was done, after which the patient presented with a non-healing discharging sinus at the same site. The exact nature of the disease was known only after excising the sinus tract with the affected rib.

[Tuberculous thoracic parietal abcess. Report of 4 cases]

Cold abcess of the chest wall is a rare extra-pulmonary tuberculous location, usually described in cases of severe or disseminated form of tuberculous. His frequency is estimated for 1 to 5% of osteoarticular tuberculous. Four cases of cold abcess of the chest wall are reported. Three of the patients are more than 65- year- old and a 30-year-old woman. In three cases, abcess is developped in the posterior chest wall and it is sternal in the fourth case . Neither immunodepression nor previous tuberculous history or other location of the tuberculosis were noted. Diagnosis is based on demonstrating mycobacterium tuberculosis in pus culture in three cases and on histologic pattern in the last one. Classic anti-tuberculosis treatement was prolonged at 12 and 15 months in 2 patients because of respectively general and local prolonged evolution.

Pathologic features of Mycobacterium kansasii infection in patients with acquired immunodeficiency syndrome

CONTEXT

Mycobacterium kansasii is a slow-growing photochromogenic mycobacterium that may infect patients with human immunodeficiency virus (HIV) late in the course of acquired immunodeficiency syndrome (AIDS). The clinical features of pulmonary and extrapulmonary infections have been described in the literature; however, the pathology of infection has not been adequately addressed.

OBJECTIVE

This report describes the pathologic features of 12 cases of M kansasii infection in patients with AIDS.

DESIGN

The medical records, autopsy protocols, cytologic material, and histologic material from patients with AIDS and concomitant M kansasii infection at a tertiary-care medical center during 1990-2001 were reviewed.

RESULTS

Twelve cases were identified, 6 by autopsy, 5 of which were diagnosed postmortem. Four of the 12 cases had cytologic material and 4 cases had histologic biopsies available for review. Pulmonary infection was most common (9/12), and all patients in whom thoracic lymph nodes were assessed showed involvement (7/7). Abdominal infection was less frequent, with only 1 of 6, 2 of 6, and 2 of 6, demonstrating liver, spleen, and abdominal lymph node infection, respectively. Isolated infections without documented pulmonary infection included brain abscess (n = 1), ulnar osteomyelitis (n = 1), and paratracheal mass (n = 1). Cytologic and histologic material showed a wide range of inflammatory reactions, including granulomas with and without necrosis, neutrophilic abscesses, spindle-cell proliferations, and foci of granular eosinophilic necrosis. The M kansasii bacillus was characteristically long, coarsely beaded, and frequently showed folded, bent, or curved ends. Intracellular bacilli were randomly or haphazardly distributed within histiocytes.

CONCLUSION

Mycobacterium kansasii infection produces predominantly pulmonary infection in late-stage AIDS with a high incidence of thoracic lymph node involvement and a much lower incidence of dissemination to other sites. Infection is manifest as a wide variety of inflammatory reactions on cytology and histology; however, the characteristic appearance of the bacillus on acid-fast bacilli stain and its intracellular arrangement in histiocytes can allow a presumptive identification.

Anterior chest wall abscess caused by Salmonella enteritidis in a healthy adult

We report a case of anterior chest wall abscess in an immunocompetent adult by Salmonella enteritidis, whose food was contaminated by bird droppings. The patient did not have any gastrointestinal symptoms. Surgical excision followed by antibiotics (cefuroxime and ciprofloxacin) successfully treated the condition. To our knowledge, this is the first reported case of anterior chest wall abscess caused by S. enteritidis in an immunocompetent adult without any preceding gastrointestinal symptoms. We feel that the contamination of his food with the bird droppings was a risk factor.

Thoracic sequelae and complications of tuberculosis

Pulmonary tuberculosis is caused by Mycobacterium tuberculosis when droplet nuclei laden with bacilli are inhaled. In accordance with the virulence of the organism and the defenses of the host, tuberculosis can occur in the lungs and in extrapulmonary organs. A variety of sequelae and complications can occur in the pulmonary and extrapulmonary portions of the thorax in treated or untreated patients. These can be categorized as follows: (a) parenchymal lesions, which include tuberculoma, thin-walled cavity, cicatrization, end-stage lung destruction, aspergilloma, and bronchogenic carcinoma; (b) airway lesions, which include bronchiectasis, tracheobronchial stenosis, and broncholithiasis; (c) vascular lesions, which include pulmonary or bronchial arteritis and thrombosis, bronchial artery dilatation, and Rasmussen aneurysm; (d) mediastinal lesions, which include lymph node calcification and extranodal extension, esophagomediastinal or esophagobronchial fistula, constrictive pericarditis, and fibrosing mediastinitis; (e) pleural lesions, which include chronic empyema, fibrothorax, bronchopleural fistula, and pneumothorax; and (f) chest wall lesions, which include rib tuberculosis, tuberculous spondylitis, and malignancy associated with chronic empyema. These varieties of radiologic manifestations can mimic other disease entities. Therefore, recognition and understanding of the radiologic manifestations of the thoracic sequelae and complications of tuberculosis are important to facilitate diagnosis.

Transthoracic aspiration cytology for the diagnosis of thoracic infection

The article describes the use and results of transthoracic aspiration cytology for diagnosis of thoracic infection in a Thai referral chest center. We reviewed 60 cytologic samples, initially diagnosed as thoracic infection or inflammation among a total of 532 percutaneous transthoracic needle aspirations obtained from patients with clinical suspicion of malignancy in a period of 6 years. Follow-up clinical data were collected and correlated with cytologic diagnosis. We found specific microorganisms in 8 samples (13.33%). These included 4 cases of actinomycosis, 3 cases of cryptococcosis and a case of aspergillosis. Granulomatous inflammation was found in 12 samples (20.00%). Among these patients, 10 cases were verified as having tuberculosis. The remaining 40 samples (66.67%) revealed acute inflammatory exudate with no specific microorganism. Follow-up clinical data confirmed or assumed infection in 27 cases. Therefore, in patients with thoracic infection who presented with clinical suspicion of malignancy, from our experience, aspiration cytology revealed adequate morphology for accurate diagnosis which resulted in prompt specific treatment and better prognosis.

[A method for the surgical treatment of patients with chronic postoperative osteomyelitis of the sternum]

The authors share their experiences with diagnosing and surgical treatment of chronic postoperative osteomyelitis of sternum developed in 36 patients after operations on the heart, lungs and organs of mediastinum. The purulent process can be liquidated in all the patients due to performing saving resection of the sternum and plasty of the bone defect with local tissues, application of a gauze-cotton roll pressing the subcutaneous fat into the bone defects formed after treatment of the affected portions of the sternum, administration of antibiotics according to sensitivity of the microflora.

The oral cavity as a reservoir of bacterial pathogens for focal infections

Dental procedures, but more importantly, oral infections and poor oral health can provoke the introduction of oral microorganisms into the bloodstream or the lymphatic system. The subsequent attachment and multiplication of these bacteria on tissues or organs can lead to focal oral infections. Pathogenic agents may also remain at their primary oral site but the toxins liberated can reach an organ or tissue via the bloodstream and cause metastatic injury. Finally, metastatic inflammation may result from an immunological injury caused by oral bacteria or their soluble products that enter the bloodstream and react with circulating specific antibodies to form macromolecular complexes.

Actinomycosis in HIV infection: a review of a rare complication

The emergence of the human immunodeficiency virus (HIV) and the onset of the AIDS epidemic has been associated with the frequent presentation of otherwise rare opportunistic infections and neoplasms. Despite the impairments of cellular and humoral immunity that accompany HIV infection, the prevalence of actinomycosis in the HIV-infected population has remained low. This article reviews previously reported cases of actinomycosis in HIV-positive and AIDS patients. Microbiological, pathological, diagnostic, clinical and therapeutic aspects of actinomycosis in this population are discussed. Clinicians should be aware of the possibility of actinomycosis as the cause of a persistent inflammatory lesion in these patients and know the correct techniques for collecting and submitting tissue specimens for anaerobic culture.

Utility of CT scan for the diagnosis of chest wall tuberculosis

The objective of this study was to determine the utility of CT scan findings for the diagnosis of chest wall tuberculosis, excluding the spine. We reviewed 15 patients (13 Africans and 2 Indians) with chest wall tuberculosis, retrospectively. The radiologic examination consisted of a plain X-ray and a CT scan of the chest for each patient. The site of disease was the rib in 13 patients or the body of the sternum in 2 patients. One rib was involved in 11 patients, 2 contiguous ribs (one site) in 2 patients, and bilateral disease (two sites) was observed in the remaining patient. The 14 rib sites involved the posterior arc or costovertebral joint in 11 cases, the anterior arc in 2 cases, and the anterior and middle arc in 1 case. The CT scan findings were an abscess (n = 14) or a soft tissue mass (n = 2), osteolytic lesions (n = 13), periosteal reaction (n = 10), and sequestrum (n = 14). Bone sclerosis was observed only in 3 cases of rib involvement. The association of a soft tissue abscess, an osteolytic lesion, and sequestrum, especially in immigrants to France, suggests chest wall tuberculosis on CT scan.

Thoracic and abdominal blastomycosis in a horse

A 5-year-old Quarter Horse mare was examined because of lethargy, fever, and weight loss of 1 month's duration. Thoracic auscultation revealed decreased lung sounds cranioventrally. Thoracic ultrasonography revealed bilateral anechoic areas with hyperechoic strands, consistent with pleural effusion and fibrin tags. A large amount of free fluid was evident during abdominal ultrasonography. Abnormalities included anemia, hyperproteinemia, hyperglobulinemia, hyperfibrinogenemia, and hypoalbuminemia. Thoracic radiography revealed alveolar infiltrates in the cranial and caudoventral lung fields. A cavitary mass, consistent with an abscess, could be seen caudodorsal to the crura of the diaphragm. Ultrasonographic evaluation of this area revealed a hypoechoic mass with septations. Bilateral thoracocentesis was performed. Bacterial culture of the pleural fluid did not yield growth, but Blastomyces dermatitidis was isolated from pleural fluid, abdominal fluid, and an aspirate of the abscess. The mare was euthanatized, and a diagnosis of thoracic and abdominal blastomycosis was confirmed at necropsy.

Drowning and near-drowning--some lessons learnt

Over a period of sixteen months, 17 cases of submersion injury (encompassing victims of drowning and near-drowning) were attended to at our Accident and Emergency Department at Changi General Hospital. Most of the victims were inexperienced recreational swimmers, and in 6 of them, early bystander cardiopulmonary resuscitation enabled them to recover without severe morbidity. Non-cardiogenic pulmonary oedema with resulting chest infection was the commonest complication in survivors. Most of the episodes occurred in an urban setting in swimming pools without supervision by lifeguards. About two-thirds of the cases were adults over the age of fifteen years. In addition, there were patients in whom submersion injury was associated with more sinister conditions (fits, traumatic cervical spine injury, dysbarism, intoxication from alcohol or drugs), some of which were unsuspected by the doctors initially. Apart from the immediate threats of hypoxia and pulmonary injury, active search for any possible precipitating causes and associated occult injury should be made. In this study, the determinants of survival from near-drowning were early institution of cardiopulmonary resuscitation, presence of pupil reactivity, and presence of a palpable pulse and cardiac sinus rhythm.

Aspergillus and other fungi

Opportunistic infections that arise in the immunocompromised host are a major cause of morbidity and mortality. Although bacterial infections are more frequent, invasive fungal infections occur commonly and carry higher risks in these immunocompromised patients. Newer antifungal agents, along with an occasional pulmonary resection, have improved the treatment options and the survival from invasive fungal infections in immunocompromised patients.

[Case report: subcutaneous abscess and thoracic empyema caused by Alcaligenes xylosoxidans]

Alcaligenes xylosoxidans is a glucose-nonfermentative gram-negative rod which usually exists in the environment. This organism while causing pneumonia, sepsis, meningitis and urinary tract infection in the compromised host, rarely causes thoracic empyema. We report a case of thoracic empyema and subcutaneous abscess due to A. xylosoxidans. A 74-year-old male, who had undergone right total pneumonectomy for chronic necrotizing pulmonary aspergillosis a year ago, was admitted to our hospital because of fever. CT scans of the chest revealed a subcutaneous abscess and empyema. Empyema and subcutaneous pus were aspirated. Culture of materials produced A. xylosoxidans. There was no significant change on symptoms and examinations despite therapy with PIPC 4 g/day and thoracic drainage. Finally, surgical treatment was required and the patient was cured.

Broncholithiasis and thoracoabdominal actinomycosis from dropped gallstones

We report a case of successfully managed invasive, thoracoabdominal actinomycosis caused by the intraperitoneal spillage of gallstones during laparoscopic cholecystectomy. The infected gallstones traversed the diaphragm, migrated into the lung parenchyma, and obstructed a segmental bronchus, causing pneumonia. Treatment involved retrieval of the obstructing stone, debridement and drainage of the pleuroperitoneal phlegmon/abscess, and intravenous antibiotics. The case illustrates the need to remove gallstones at the time of cholecystectomy.

The role of esophagectomy in the management of esophageal perforations

BACKGROUND

Despite the many advancements made in thoracic surgery, the management of patients with esophageal perforation remains problematic and controversial.

METHODS

Between 1985 and 1995, 27 esophagectomies were performed for perforation of the thoracic esophagus. A retrospective review of the records of these patients was carried out, and a scoring scale developed by Elebute and Stoner to grade the severity of sepsis was applied.

RESULTS

Among the 27 patients undergoing esophagectomy for a perforation, the interval between rupture and esophagectomy was less than 24 hours in only 11 patients (40.7%). Postoperative surgical complications occurred in 4 patients (14.8%) and nonsurgical complications, in 7 (25.9%). The hospital mortality rate was 3.7% (1/27). In 14 patients, primary reconstruction was performed in the bed of the excised esophagus. There were no anastomotic leaks in this subgroup. This suggests that an anastomosis between viable, well-vascularized tissues is more important for successful healing than avoidance of some degree of contamination of the adjacent mediastinum. On follow-up, which averages 41 months, 73% of patients (16/22) have neither symptoms nor complaints.

CONCLUSIONS

Esophageal resection definitively eliminates the source of intrathoracic sepsis, the perforation, and the affected esophagus. Reconstruction carried out in one stage does not increase operative morbidity. Esophageal resection and reconstruction is a valid approach even in cases of spontaneous perforation in which the diagnosis is markedly delayed.

Analysis of status of surgery in thoracic tuberculosis

A retrospective analysis of the surgical procedure in 1655 patients in twenty years in a university hospital for thoracic tuberculosis revealed that the varieties of procedures were necessary in 2.2% cases only. They can be grouped as tubercular empyema with or without bronchopleural fistula in 1507 (91%), complicated pulmonary tuberculosis in 78 (4.7%), cold abscess in the chest wall with or without lymphadenitis in 54 (3.2%) and osteomyelitis of the ribs and sternum in 16 cases (0.9%). This is statistically significant with a confidence interval of 0.1248 to 0.2348. In tubercular empyema 222 procedures were performed of which 162 were minor procedures, intercostal drainage with irrigation: 89 cases, thoracostoma: 56 cases and continuous chest wall tube 17 cases and 60 were major procedures (decortication in 45 cases, thoracoplasty [modified] in 14 cases and muscle transfer in one case). All the above procedures were preceded by an intercostal drainage. In complicated pulmonary tuberculosis the operative procedures were as follows: lobectomy in 33 cases, pneumonectomy in 35 cases and thoracoplasty in 10 cases. Drainage of cold abscess with or without lymphnode resection was performed in 54 cases and in 16 cases of osteomyelitis of the ribs and sternum resection were necessary. All procedures were performed under the cover of antitubercular therapy and supportive treatment with the aim of resolution of process, obliteration of the empyema space, control of sepsis and improvement of activity performance. The morbidity was extensive and mortality was high in major procedures. Good results could be obtained in over 92% cases, and only 66.2% on major surgery cases.

[Thoracic infections in immunocompetent patients. The contribution of computed tomography]

Chest X-Ray is the most accurate method of imaging for infectious diseases in an immunocompetent patient. Computed tomography (CT) may be useful in certain circumstances, particularly in case of atypical findings at the time of diagnosis or in case of complications. CT helps to detect and perform a complete study of the lesions, some aspects being very suggestive of a diagnosis, as in post-primary active tuberculosis. CT may also detect an unknown underlying etiology. Multiplanar reformations with helical CT can be useful for example in case of empyema. In case of non tuberculous bacterial infections, CT is mainly recommended when abscess and empyema are difficult to differentiate or in case of pleural complications with possible percutaneous treatment. In case of tuberculosis, CT may be indicated when clinical and chest X-Ray findings are discordant, in case of mediastinal adenopathies, when reactivation is suspected or in case of complications as hemoptysis. A baseline CT examination could be proposed at the end of a specific treatment to facilitate the diagnosis of reactivation tuberculosis. A nontuberculous mycobacterial infection should finally be suspected in front of peculiar CT findings.

Chest wall tuberculosis simulating breast carcinoma: imaging appearance

Tuberculosis of the breast is a rare disease. Tubercular abscesses predominantly affecting the soft tissues are also very infrequent. A case of chest wall tuberculosis secondarily involving the breast presenting as a hard, fixed lump simulating mammary carcinoma is presented here. There was no evidence of pleural or pulmonary tuberculosis.

Symmetrical necrotising chest wall infection following paronychia

Paronychial infection is a common condition seen in the accident and emergency department. Treatment is by antibiotics or incision and drainage under local anaesthetic. Complications are rare but may occur if treatment is delayed or inadequate. A case is described of symmetrical necrotising chest wall infection, of unusual anatomical distribution, that occurred following a paronychia and required surgical debridement and skin grafting.

[Surgery of thoracic and pulmonary tuberculosis and the sequelae of its treatment in adults]

Surgery for tuberculosis was the starting point for thoracic and cardiovascular surgery in the modern day, but its place was more and more restricted to the treatment of the disease. Excisions (lobectomies, pneumonectomies, segmentestomies) currently represent the majority of operations, after this come operations on the pleura (decortication) and rarely those on the thoracic wall (thoracoplasty, parietectomy). The indications for excision are principally encountered with disease of the parenchyma itself: progressive disease under treatment or with resistant tubercle bacilli, sequelae of parenchymal complications (infections, aspergilloma or haemoptysis) and certain forms of atypical mycobacteria, and also a small but significant group in which excisions are aimed at diagnosis. Sometimes excisions are associated by necessity with decortication for pleural disease which may or may not have originally been intended for the underlying parenchyma or the lesions may be the sequelae of previous complications of treatment such as collapse therapy. Occasionally surgery is indicated in the treatment of lymph node masses in the mediastinum which have not responded to antituberculous therapy and during the treatment bronchial complications have evolved or there have been other sequelae. As for the indications for surgery of the thoracic wall such as thoracoplasty, they appear more than ever obsolete and even if they are still used in certain complications of surgery, they have apart from a few exceptions, lost their original therapeutic role in tuberculosis. However, currently there is a recrudescence of tuberculosis favoured by certain socio-economic situations and strengthened by the appearance of TB cultures which are more and more resistant. The surgery of tuberculosis in its oldest forms (thoracoplasty and removal of cavities) can no longer be said to be the surgery of the past. They proved in the old days that they could cure. Surgery has once more its place in the therapeutic arsenal of new forms of the disease and indirectly in limiting the risk of spread it has a role to play in prevention.

Herniation of the stomach and necrotizing chest wall infection following laparoscopic Nissen fundoplication

This paper addresses gastric herniation following laparoscopic fundoplication for reflux esophagitis.

CASE HISTORY

A 46-year-old woman underwent Nissen fundoplication. Two days postoperatively she developed gastric herniation and perforation with subsequent pleural effusion and necrotizing fasciitis of the chest wall. A patent crural repair might reduce the occurrence of paraoesophageal herniation.

Selective use of tracheostomy in surgery for head and neck cancer: an audit

This retrospective study was designed to define the role of tracheostomy in the operative treatment of patients with cancers of the head and neck. The subjects were 51 patients who underwent neck dissection with resection of the tumour and repair during the period January 1992-December 1994, out of a total of 109 patients who were treated for cancers of the head and neck during that time. Three patients required tracheostomies, two of which were done preoperatively, and one immediately postoperatively for respiratory distress. There were no operative deaths. Morbidity included wound infection (n = 2), chest infection caused by Haemophilus influenzae (n = 1), transient fever associated with blood transfusion (n = 5), and transient fever of no obvious cause (n = 3). Median hospital stay was 10 days (range 4-38). Patients undergoing operations for cancers of the head and neck do not require routine tracheostomy. Further research on how to select patients who will need tracheostomy is necessary and is being done.

Causes and management of intestinal obstruction in a Saudi Arabian hospital

A retrospective review of 84 cases of intestinal obstruction admitted to the National Guard Hospital over a period of 10 years was carried out. The main causes of obstruction were: post-operative adhesions, 38 patients (45%); hernia, 17 (20%); pseudo-obstruction, eight (9.5%); intussusception, six (7%); malignant obstruction, four (4.8%); inflammatory obstruction, three (3.6%); volvulus, three (3.6%); and others, five (6%). Large bowel obstruction occurred in only 16 patients (19%). Surgical intervention was necessary in 61 patients (73%) while 23 patients (27%) responded to conservative treatment. Post-operative complications occurred in 14 patients (17%). The main complications were: wound infection, chest infection, prolonged ileus and intestinal fistulae. The mortality rate was 3.5%. The pattern of small bowel obstruction in Saudi Arabia is similar to that in the West, while large bowel obstruction is rather uncommon.

Factors predisposing to median sternotomy complications. Deep vs superficial infection

STUDY OBJECTIVES

Median sternotomy infections are a serious complication of cardiac surgery. The purpose of this study was to determine the patient characteristics and operative variables that predict incidence of sternal infection, and possibly its severity.

DESIGN

Univariate and multivariate retrospective analysis comparing patient, operative, and post-operative data in patients with and without sternal infections.

SETTING

Cardiac surgery program of a 580-bed private hospital in Toledo, Ohio.

PATIENTS

We studied 2,317 consecutive (June 1991 to December 1994) patients undergoing cardiac surgery.

RESULTS

Forty-one sternal infections were documented. Of these, 21 (0.91%) were deep infections with mediastinal involvement and 20 (0.86%) were superficial. Two patients with deep infections died (2/41, 5%). Ten variables were associated with infection by univariate analysis (p < 0.05), and of these, five were independent predictors by multivariate logistic regression. These predictors were obesity (p < 0.001), insulin-dependent diabetes (p < 0.001), use of internal mammary artery grafts (p = 0.02), surgical reexploration of the mediastinum (p = 0.003), and postoperative transfusions (p = 0.01). Predictors of deep and superficial sternal infection did not differ. Length of hospitalization was substantially longer for patients with deep (32 +/- 21 days) vs superficial infection (13 +/- 10 days).

CONCLUSIONS

The present study confirms previous findings that obesity, insulin-dependent diabetes, and internal mammary artery grafting (especially bilaterally) increase the risk of sternal infection. In addition, chest surgical reexploration and blood transfusions were postoperative factors that predisposed patients with median sternotomy to infection. Unlike their associated morbidity and mortality, predictors of deep and superficial sternal infections are similar.

[Thoracic actinomycosis]

The authors describe in their case study the history of a 51 year old man, at whom they verified without thoracotomy thoracal actinomycosis. They achieved recovery giving permanently high doses of Penicillin. In connection with this rare case the authors review pathogenesis, the symptomatology, the diagnosis and the therapy of actinomycosis. The authors have found only one case in the Hungarian literature, which was recognized without thoracotomy and was cured by antibiotic therapy within a short period of time.

Radiologic-Pathologic Conference of Children's Hospital Boston: chest wall mass in an infant with eczema

A 2-month-old infant with fever and a chest mass is presented. Imaging evaluation, differential and final pathological diagnosis are discussed.

Chest wall actinomycosis in association with the use of an intra-uterine device

A 31 year old woman presented with a chest wall abscess due to Actinomyces israellii and Porphyromonas asaccharolytica (previously Bacteroides asaccharolyticus). She was a long-term user of an intra-uterine device (IUD) and, although asymptomatic, had radiological evidence of pelvic infection. Actinomyces-like organisms were seen on cervico-vaginal smears. The abscess was surgically drained, the IUD removed, and a prolonged course of amoxycillin/clavulanic acid given.

Actinobacillus actinomycetemcomitans pneumonia with chest wall and subphrenic abscess

A 14-year-old girl had progressive dyspnea and right lower chest pain for about 1 1/2 months and a weight loss of 3 kg in 2 months. Chest X-ray revealed right pleural effusion and a round infiltration over the right lower chest, initially suspected to be malignant. Image study revealed consolidation in the right middle and lower lobes with abscess-like lesions around the right lower pleura and transdiaphrenic involvement to the subphrenic region. The lesion had also invaded the intercostal muscle. The pleural abscess was obtained by fiberoptic thoracoscopy, and culture of the pus grew typical colonies of Actinobacillus actinomycetemcomitans. After the causative microorganism had been identified, cefoxitin was given for 2 weeks followed by oral amoxicillin (250 mg/6 h) for a total period of 3 months. Follow-up chest X-ray revealed resolution of the lung lesions and the patient recovered gradually without any sequelae.

Management of primary chest wall tuberculosis

Primary tuberculosis of the chest wall is rare and its clinical presentation may resemble pyogenic abscess or tumour. The diagnosis is difficult, since smears or cultures of aspirate frequently fail to show tubercle bacilli. Seven cases of primary chest-wall tuberculosis treated between 1973 and 1992 are described. All presented with a progressively enlarging mass. The diagnosis was based on bacteriologic and histologic findings, but definitive diagnosis was obtained before treatment in only two cases. Satisfactory results were obtained with surgical debridement and specific chemotherapy in six cases and with chemotherapy alone in one case. From this limited experience, we suggest that primary chest-wall tuberculosis should initially be treated with a combination regimen of antituberculous chemotherapy, which should take more than 9 months. If the lesion progressively enlarges or secondary infection occurs, however, adequate surgical debridement is also required.

Actinomycosis in fine needle aspiration cytology

Four cases of actinomycosis were diagnosed by fine needle aspiration (FNA) cytology and eight more cases were detected during a review of FNA smears reported as inflammatory. The age of these 12 cases ranged from 20 to 61 years with a median of 35 years. The male to female ratio was 3:1. The common regions of involvement were cervicofacial in seven cases (58.3%), thoracic in three (25.0%) and abdominal in two (16.7%). Four of the seven cervicofacial cases presented with intra-oral masses; the thoracic lesions were pulmonary in location, and the abdominal lesions presented as bowel masses. The possibility of actinomycosis was not considered clinically in any case. The main reason for missed cytodiagnosis in two thirds of the cases appeared to be observer error. It is suggested that when the aspiration smear from a mass is found to be an inflammatory exudate rich in neutrophils, special efforts must be made to look for this microorganism.

Necrotizing fasciitis and myositis: a case report

Necrotizing fasciitis is a relatively rare, potentially life-threatening infection involving the subcutaneous tissues. We report a case of group A streptococcal necrotizing fasciitis/myositis in which CT played an important role in differential diagnosis.

[Thoracic actinomycosis]

BACKGROUND

Thoracic actinomycosis is an rare disease in our medium. This fact, together with the variability of its forms of presentation and the difficulty in isolating its etiologic agent, make its diagnosis, particularly difficult.

METHODS

A series of 8 cases diagnosed in the years 1988, 1989 and 1990 in two centers (Hospital de Bellvitge-Prínceps d'Espanya and Hospital de l'Esperança) is described with evaluation of the clinical and analytical data and the therapy applied.

RESULTS

Species were only identified in 3 cases with Actinomyces israelii in two and Actinomyces odontolyticus in the third. The proven association with Mycobacterium tuberculosis, the presence of distant septic metastasis and eosinophilic pleuritis as forms of presentation are of note. Medical treatment was penicillin or derivatives in all the cases except one which was treated with diagnostic/therapeutic segmentectomy.

CONCLUSIONS

It is concluded that when any subacute involvement of the thoracic and/or pleuropulmonary wall specific cultures should be carried out to discard eventual thoracic actinomycosis.

Thoracic complications of deeply situated serous neck infections

Nine cases of complicated deep neck infections, occurring during a period of twelve years are presented. Complications observed were cervico-thoracic necrotizing fasciitis in 3 cases, purulent pleural effusion in 6 cases, pericardial effusion in 2, mediastinitis in 8 cases, jugular vein thrombosis and rupture of the innominate artery in one case each. Although 2 cases were managed initially with blind endotracheal intubation, all cases finally required tracheostomy. A cervico-mediastinal approach was useful for the early mediastinal involvement. Two patients died because of inadequacy of the multiple surgical procedures resulting in persistent infection and multi-organ failure and one because of uncontrollable bleeding after innominate artery rupture.

Thoracic actinomycosis: an unusual childhood infection

I have reported a rare case of thoracic actinomycosis in a child with a chest wall mass and pneumonic infiltrate. This case emphasizes the possibility of actinomycosis occurring in a well child with no previous dental problems, chronic lung disease, loss of consciousness, or immunocompromised status. The findings on thoracic computed tomography contributed to the early consideration of actinomycosis in the differential diagnosis.

[A case of chest wall abscess due to Salmonella newport]

A 18-year-old female with a history of precordial pain was admitted. There was a mass (3.5 x 2.5 cm) in the right inframammary region which was suspected to be chest wall tumor on the basis of CT scan and Ga scintigraphy findings. Exploratory surgery, consisting of total resection of the tumor without removing the ribs, was performed and revealed an abscess. Culture of pus from the abscess grew Salmonella newport (0 antigen 8, H antigen eh; 1.2). Focal infection with Salmonellosis is discussed. Surgical treatment is necessary in addition to chemotherapy.