Deep Soft Tissue Research Articles

Factors associated with positive findings of deep infection on computed tomography among patients with extremity cellulitis.

Cellulitis shares several clinical features with fulminant deep soft tissue infections, creating a diagnostic dilemma for which clinicians are increasingly using cross-sectional diagnostic imaging to resolve. However, the role of imaging in apparent cellulitis is poorly defined. In particular, the clinical utility of CT in extremity cellulitis is underexplored. The purpose of this study was to determine patient and clinical factors that increase likelihood for finding of deep infection on CT among patients with extremity cellulitis. A retrospective observational study was performed of patients with cellulitis of the extremities who were examined with computed tomography from January 1, 2012 to December 31, 2021. Demographics, medical history, and clinical and laboratory characteristics were collected. The presence of positive findings on CT report was recorded. Repeated measures logistic regression was used to evaluate significant predictors of positiveCT. There were 496 eligible patient encounters, and CT was positive for deep infection in 39 cases (7.9 %). Median patient age was 56years of age, 58.1 % were male, and most patients had a history of diabetes mellitus, history of tobacco use, and/or obesity. Significant predictors for positive CT on multivariable analysis included gas on pre-CT radiographs, febrile leukopenic state, injection drug use, purulence on exam, and white blood cell count extremes. Elevated CRP was also a significant positive predictor on bivariate analysis. Finding a deep infection on CT in a patient with extremity cellulitis is uncommon and is predominantly associated with a high-risk clinical picture, and/or with high index of suspicion based on pre-CT plain films. In the absence of these patient factors or compelling findings on radiographs, CT does not typically provide clinically actionable information for extremity cellulitis and should not be used as part of standard evaluation.

Unusual encounter: Isolation of Carnobacterium divergens in an immunocompetent patient with a meat grinder Injury. Case report

The genus Carnobacterium belongs to lactic acid bacteria, this group are composed by 12 species. These microorganisms are associated with mucosal surface, present in food-related habitats including plant, wine, milk, and meat environments. In humans, evidence of Carnobacterium spp., about the disease spectrum remains unknown. Current work is about a 25-year-old male, was admitted to the emergency room for transmetacarpal traumatic amputation of his left hand caused by a meat grinder. In deep soft tissue samples obtained from surgery, Carnobacterium divergens was isolated. He was treated with piperacillin-tazobactam and was switched to amoxicillin-clavulanate for five more days with clinical success. Written informed consent was obtained from the participating patient for publication of this case report and any accompanying images. Therefore, the pathogenic role of Carnobacterium spp., remains unknown and classically is not considered pathogenic to humans. However, in previous cases where was associated with infection, the described outcomes were good. The misidentification showed that conventional identification methods are not accurate.

Complicated and deep bacterial skin and soft tissue infections.

Complicated erysipelas, cellulitis, and necrotizing soft tissue infections belong to the spectrum of bacterial infections affecting the skin and underlying soft tissues. Their frequency as well as risk of recurrence and complicated disease course pose a significant health burden. The latter is further impacted by global travel activity, associated variations in the prevalence of microbes, the emergence of multi-resistant bacteria, demographically driven aging with an increase in critical comorbidities, immunosuppressive therapies, and excessive (including non-medical) use of antibiotics. Against this background, early and accurate diagnosis and promptly initiated therapeutic measures are major determinants in prognosis and clinical outcome. Diagnostic evaluation involves clinical, laboratory, microbiological, and radiographic findings, which are assessed in the context of patient-specific risk factors and comorbidities. First and foremost, given the indication, exploratory incisions of lesional tissue should be performed, allowing rapid assessment of the extent of tissue necrosis and providing guidance on the scope and extent of further (surgical and non-surgical) treatment modalities. Thus, delayed or inadequate interventions can be avoided, which reduces the duration of treatment, health expenses, the risk of recurrent hospitalizations, and mortality rates.

Rectum Perforation Complicated Necrotizing Fasciitis Present as Lumbar Disc Herniation: Case Report.

Necrotizing fasciitis (NF) is an infection of the deep soft tissues that results in progressive destruction of the muscle fascia and overlying subcutaneous fat. These infections can be sudden, vicious, and fast-spreading. If not treated quickly with antibiotics and debridement of the infected tissue, the patient may develop septic shock, which may lead to multiple organ failure and death. NF is difficult to early diagnose due to the overlying tissue can appear unaffected initially. We report an unusual case of NF of the buttock and left thigh that clinically mimics lumbar disc herniation. This patient was successfully treated with emergent fasciotomy and intensive care. We recommend that patients with low back pain and unilateral leg pain should be diagnosed carefully especially keeping NF in differential diagnosis.

Ematoma, infezione e difetto della coagulazione

Febrile limp in paediatric patients is often associated with septic arthritis, but alternative diagnoses must be considered. The paper reports the case of a 10-year-old boy with intermittent fever and persistent coxalgia. Imaging revealed multiple abscess-like collections in the gluteal and thigh muscles. An improperly disinfected knee wound and factor VII deficiency contributed to infected hematoma formation. The isolation of MRSA producing Panton-Valentine leukocidin required targeted antibiotic therapy and surgical drainage. This case highlights the importance of careful differential diagnosis and a multidisciplinary approach in managing deep soft tissue infections.

Clear Cell Sarcoma (CCS) of the Soft Tissue: An Update Narrative Review with Emphasis on the Utility of PRAME in Differential Diagnosis.

Clear Cell Sarcoma (CCS) of soft tissue is a rare and highly malignant neoplasm primarily affecting young adults, often presenting in the deep soft tissues of the extremities. Despite morphological and immunophenotypic similarities to melanoma, CCS arises from connective tissues and is characterized by a distinct genetic hallmark: the EWSR1-ATF1 fusion resulting from t(12;22)(q13;q12) translocation. This genetic signature is absent in melanoma, making molecular diagnosis essential for accurate differentiation. Additionally, recent evidence highlights the utility of PRAME as an immunohistochemical marker to distinguish CCS from melanoma and other neoplasms. Clinically, CCS commonly involves tendons and aponeuroses, with metastatic potential leading to poor prognoses despite optimal local disease management. Histologically, CCS features lobular growth, spindle-to-epithelioid cells with clear cytoplasm, and low mitotic activity, often necessitating a multimodal diagnostic approach incorporating histopathology, immunohistochemistry, and molecular testing. Therapeutically, wide surgical excision remains the cornerstone for localized disease, with sentinel lymph node biopsy aiding in staging. Adjuvant radiotherapy is considered in select cases, while chemotherapy has limited efficacy in metastatic settings. Emerging treatments, including targeted therapies focusing on EWSR1-ATF1-driven pathways and immune checkpoint inhibitors, offer hope for improved outcomes. This review synthesizes current knowledge on CCS, emphasizing diagnostic challenges, the role of PRAME, and advancements in therapeutic strategies to enhance patient care.

P-403. Incidence of Surgical Site Infections in Selected Tertiary Care Hospitals in Bangladesh: Findings From A Pilot Surveillance Project

Abstract Background Surgical site infections (SSI) are the most frequent type of healthcare-associated infections (HAI) and SSIs have substantial healthcare ramifications. In Bangladesh, most hospitals lack surveillance systems for HAIs, including SSI. We conducted this SSI surveillance to assess the rate and determine measures of SSI burden in Bangladesh Common Organisms for Surgical Site Infections in Bangladesh Common Organisms for Surgical Site Infections in Bangladesh Methods From January to August 2021, we piloted SSI surveillance in four tertiary care hospitals. Participants included undergoing cesarean section (C-section) or abdominal surgery. We enrolled SSI cases if any infection occurred within 30 days of the surgery and contained the skin, subcutaneous tissue and/or deep soft tissue, in or on any part of the anatomy. We also collected data on symptoms, antibiotic consumption, diagnosis, and treatment Results We enrolled 1,760 patients, with a majority (75.7%) undergoing C-sections. Within 30 days of surgery, 33.2% (585) of patients developed SSI symptoms. Abdominal surgery patients had a higher rate of SSI (40.9%, 175/426) compared to C-section patients (30.7%, 410/1334). Most patients (90.9%, 532/585) acquired SSI symptoms during hospital stay. Two-thirds (66.4%) of patients were prescribed antibiotics on admission, and 70.1% were given surgical antibiotic prophylaxis. Rates of SSI did not differ between those who received antibiotics or not. The most frequently prescribed antibiotics were ceftriaxone 57.5%, on admission and the combination of ceftriaxone and metronidazole (84.1%) in postoperative patients. Only 10. 7% (63/585) of participants performed wound cultures, of which 76.2% (48/63) demonstrated growth. The most frequently reported organisms were Escherichia coli (37.2%), Staphylococcus aureus (30.2%), and Klebsiella pneumoniae (20.9%). Conclusion Further study of the factors contributing to this high incidence and timing for surgical antibiotic prophylaxis administration is needed. The high rate of antibiotic consumption also suggests a need for examination of whether appropriate treatment is being administered and/or if antibiotic prophylaxis is targeting the correct organisms. Additionally, strengthening IPC practices, establishing antimicrobial stewardship programs, and updating antibiotic guidelines could help prevent SSIs and AMR in Bangladeshi hospitals Disclosures All Authors: No reported disclosures

Invasive group A streptococcal infections as a consequence of coexisting or previous viral infection in the post-COVID-19 pandemic period.

Invasive group A streptococcal infections as a consequence of coexisting or previous viral infection in the post-COVID-19 pandemic period.

Benign Glomus Tumor of the Urinary Bladder: A Case Report and Literature Review.

Glomus tumor is a rare neoplasm, typically found in superficial soft tissues and extremities, particularly in the subungual region. However, it can also occasionally affect deep soft tissue or viscera, such as the bladder, albeit infrequently. Our patient was a 51-year-old man presenting with recurrent hematuria of unknown etiology, accompanied by a blood clot that resolved spontaneously after 1 day. Abdominal computed tomography revealed multiple calculi in the right kidney, whereas cystoscopy showed mucosal edema on the left side of the bladder. A magnetic resonance image of the bladder identified an ovoid mass on the left side, measuring approximately 3.1 cm × 2.7 cm × 2.1 cm. This mass demonstrated a slightly increased signal intensity on T2-weighted images and an intermediate signal intensity on T1-weighted images. These findings suggested a malignant tumor in the urinary bladder with a nonfunctional right kidney. The patient underwent laparoscopic surgery to remove the right kidney and part of the bladder. Histologically, the tumor primarily consisted of round cells and abundant eosinophilic or pale cytoplasm. Immunohistochemical staining demonstrated diffuse positivity for smooth muscle actin and vimentin, and focal positivity for synaptophysin. The final pathological diagnosis was a bladder glomus tumor. At 15 months after resection, the patient was in good health with no recurrence or metastasis. The clinical manifestations and imaging features of bladder glomus tumors can pose diagnostic challenges for urologists. Therefore, it is imperative to consider this tumor in the differential diagnosis of bladder tumors and to enhance the understanding among urologists and pathologists regarding this entity.

Clear Cell Sarcoma of the Parotid Gland: Case Report and Review of the Literature.

Clear cell sarcoma (CCS) of the parotid gland is a rare and aggressive cancer, predominantly affecting the deep soft tissues of the lower extremities, and is more frequently observed in the elderly. Its occurrence in the head and neck area, particularly in the parotid gland, is exceedingly rare. This study presents a 75-year-old male who exhibited a substantial, swiftly-enlarging mass on the left side of the mandible, which was diagnosed as CCS of the parotid gland. Morphologically and immunohistochemically, CCS shares characteristics with melanomas, and Ewing sarcoma, complicating differential diagnosis. The primary treatment for localized CCS typically involves surgical excision with clear margins. However, due to its resistance to conventional chemotherapy, there is ongoing research regarding the efficacy of adjuvant therapies such as chemoradiation, lymphadenectomy as well as immunotherapies such as immune checkpoint inhibitors. Further research is imperative to enhance our understanding of CCS and to develop more effective treatment strategies.

Primary Intraosseous Solitary Fibrous Tumor of the Mandible: Report of a Diagnostically Challenging Case with NAB2::STAT6 Fusion and Review of the Literature.

Solitary fibrous tumor (SFT) represents an uncommon mesenchymal neoplasm affecting primarily the extremities and deep soft tissues with, overall, benign but locally aggressive biologic behavior and an underlying pathognomonic NAB2::STAT6 fusion. Intraosseous SFTs are infrequent, and involvement of the jawbones is exceedingly rare. A 54-year-old woman presented with an asymptomatic, well-demarcated, multilocular radiolucency of the left posterior mandible featuring focally irregular borders, root resorption and lingual cortex perforation. The lesion had shown progressive growth over a 6-year period. Microscopically, a proliferation of predominantly ovoid and spindle-shaped cells with indistinct cell membrane borders, elongated, plump or tapered, hyperchromatic nuclei, and lightly eosinophilic cytoplasm was noted. Marked cytologic atypia, pleomorphism and mitoses were absent. A secondary population of epithelioid cells exhibiting ovoid or elongated vesicular nuclei, and abundant, pale eosinophilic or vacuolated cytoplasm was also present. The supporting stroma was densely fibrous with areas of marked hyalinization and variably-sized, ramifying, thin-walled vessels. By immunohistochemistry, lesional cells were strongly and diffusely positive for STAT6 and CD99, and focally immunoreactive for MDM2 and SATB2. Ki-67 was expressed in less than 5% of lesional cells, while most interspersed epithelioid cells were positive for the histiocyte marker, CD163. Molecular analysis disclosed a NAB2::STAT6 fusion confirming the diagnosis of SFT. The patient underwent segmental mandibulectomy. Herein, we report the first case of primary intraosseous SFT of the mandible with complete documentation of its characteristic immunohistochemical and molecular features. Diagnosis of such unusual presentations may be further complicated by the challenging histomorphologic diversity of SFT.

Dedifferentiated Liposarcoma of the Parotid Gland: A Rare Presentation.

Dedifferentiated liposarcoma (DDLPS) is a nonlipogenic sarcoma arising in association with well-differentiated liposarcoma (LPS), and represents 10% of liposarcomas. Most of the cases of dedifferentiated liposarcoma arise in the retroperitoneal region, followed by deep soft tissue of the extremities, trunk, mediastinum, spermatic cord, and the head and neck region. We report a case of a 35 year old male patient who had DDLPS of the left parotid gland.

Advancing Diagnostics: The Role of Ultrasound and MR Imaging in Evaluating Musculotendinous Pathologies of the Shoulder Joint – A Comprehensive Literature Review

Musculotendinous pathologies of the shoulder joint are a common source of pain and functional impairment, often requiring precise imaging for accurate diagnosis and management. This review explores the roles of ultrasound (US) and magnetic resonance imaging (MRI) in evaluating these conditions, focusing on their diagnostic strengths, limitations, and clinical applications. Ultrasound offers dynamic, real-time assessment with high accuracy for superficial structures, making it a cost-effective option for evaluating rotator cuff tears and tendinopathies. MRI, on the other hand, is the gold standard for comprehensive imaging of deep soft tissues, labral injuries, and subtle intra-articular abnormalities. Recent advances in both modalities, including AI-powered ultrasound and faster MRI sequences, have enhanced diagnostic capabilities. This review synthesizes evidence from the past decade, comparing the sensitivity, specificity, and cost-effectiveness of US and MRI while discussing scenarios where their integration can provide the most benefit. The findings emphasize the need for modality selection tailored to clinical presentations, the expertise of practitioners, and healthcare resource availability. Future research should aim to standardize imaging protocols and explore innovative multimodal approaches to improve diagnostic accuracy further.

Silent trauma leading to necrotizing fasciitis in a diabetic patient: A case report

Necrotizing Fasciitis (NF) is a severe, rapidly spreading infection of deep soft tissues that can result in significant morbidity and mortality if not treated promptly. This condition is more common in men and primarily affects the lower limbs.

Surgically Treated Clear Cell Sarcomas — What Influences Outcomes?

Clear cell sarcoma (CCS) also called as melanoma of soft parts is a rare malignant soft-tissue tumor with melanocytic differentiation, primarily located in deep soft tissue and has preference for lymph node and pulmonary metastasis. Metastatic patients have poor oncologic prognosis and so far, no adjuvant treatment seems to be effective in these cases. All cases were retrieved from our prospectively maintained surgical database. Twenty-nine patients (14 males,15 females) with a mean age of 34 years (13–69 years) were operated between 2004 and 2020. Overall survival and recurrence free survival were evaluated. At mean follow-up of 45 months, out of 29 cases, 2 lost to follow-up, 6 patients had nodal metastasis, 3 had lung metastasis, one had both at presentation, 15 patients had died due to disease and 12 are alive. Nodal metastasis rate was 24% (7/29). Positive margin is observed in 6 (19%). 24 patients had recurrence of which 6 had both local and distant. The 5-year OS, LRFS, DRFS were 53%, 56%, 35% respectively at 5 years. Survival rates were significantly poor in patients with metastasis at presentation, 66% vs. 25% (p = 0.016). CCS is an aggressive soft tissue malignancy with high propensity for metastasis. The overall survival of CCS is poor. Metastasis at presentation negatively impacts on survival. Distant recurrences, especially nodal recurrences are not uncommon and complete surgical resection of all recurrences if possible is advisable. Research to develop new chemotherapeutic agents and targeted therapies may help improve the prognosis of CCS.

Minimally Invasive Sacroiliac Joint Fusion versus Non Surgical Management in Chronic Sacroiliitis: A Systematic Review and Meta-Analysis

Abstract Background Sacroiliac joint fusion for low back pain attributed to sacroiliac joint is beneficial in a subset of patients. However, varied conservative treatments were measured in previous studies. Moreover, there are lack of well design and long-term follow-up studies. Aim of the Work The primary objective of this study was to determine whether sacroiliac joint fusion was superior to conservative treatment for patients with low back pain in pain and function. Materials and Methods In the current metaanalysis, the 18 studies included 1457 patients with chronic sacroiliitis, from which 841 patients underwent Non-surgical management & 616 patients underwent minimally invasive SI fusion. The mean age of pooled sample is 50 years. The follow up period ranged from 2 weeks to 72 months. Results In our meta-analysis, there was significant decrease in pain scores in patient treated with minimally invasive sacroiliac joint fusion. The decrease reported in the included studies of VAS and ODI after MISJF is clinically relevant statistically significant. In terms of pain reduction: all conservative treatment modalities showed statistically significant reduction of pain at the end of follow up except in local anesthetic injection. In terms of disability score (ODI): all conservative treatment modalities showed statistically significant reduction of ODI score at the end of follow up. There was a dramatic relief of pain in cases treated with joint fusion than those treated with conservative treatment. Using EQ-5D time trade-off scale, there was improvement in patient quality of life on patient treated with joint fusion higher than in cases of conservative management, but was statistically insignificant. We found that proportion of patients who were able to walk for distance more than one kilometer were higher in case treated with joint fusion, but it was statistically insignificant. By month 24, we observed 39 severe adverse events after sacroiliac joint arthrodesis, including sacroiliac joint pain, postoperative gluteal hematoma, and postoperative nerve impingement. With conservative treatment there were no reported complications except in one study. In fusion group few complication reported mostly were : hematoma formation, piriformis syndrome, cellulitis, deep-soft tissue infection, Implant penetration, non-displaced fracture and persistent joint pain. Conclusion In cases of low back pain related to chronic sacroiliitis, improvements in pain, and disability, observed following minimally invasive SIJF surgery was statistically significant compared to non-surgical management.

Rare Abdominal Desmoid Tumor: Case Report and Review of Literature

A desmoid tumor is a clonal fibroblast proliferation, occurring in deep soft tissues with a significant recurrence tendency. Aggressive fibromatosis is a rare disease. The prevalence in the population ranges from 2 to 4 cases per million. Mentioned neoplasms are highly unpredictable in terms of development. Typically, in the course of desmoid tumors, metastases do not occur, but they often infiltrate the surrounding tissues, which may be associated with numerous complications. There are currently no randomized standards of therapy designated, which is undoubtedly a challenge when referring to treatment. To a 37 year old patient, due to a pathological mass in the abdomen, the MR examination was performed. It showed the presence of an irregular, heterogeneous structure on the right side of the abdominal cavity. A laparotomy was performed. During the procedure adhesions were released and the giant abdominal tumor was removed in one block with part of the duodenum, caecum, ascending colon and part of ileum. End-to-end duodenal anastomosis and stapled, side-to-side ileo-transverse anastomosis were used. The surgical field was being drained. The postoperative course was uneventful. Tissue material was collected for a routine, histopathological examination in which the intra-abdominal form of fibromatosis was diagnosed. The macroscopic image describes a tumor with dimensions of 25.0 cm x 25.0 cm x 20.0 cm.

Antibiotic sensitivity pattern of deep skin and soft tissue infections in Pakistan.

Objective: To determine the antibiotic spectrum of deep skin and soft tissue infections in Pakistan. Study Design: Cross-sectional study. Setting: Department of Dermatology at Madinah Teaching Hospital, Faisalabad. Period: June, 2023 to December 2023. Methods: Inclusion criteria covered consenting patients aged 15-60, excluding those with specific conditions. The study aimed to ascertain antibiotic sensitivity patterns in deep skin and soft tissue infections. Ethical approval was obtained, and subjects meeting criteria were enrolled after informed consent, contributing valuable insights into healthcare-associated infections. Results: Examining 60 patients, the age distribution indicates a prevalent cohort up to 50 years (61.7%), highlighting potential health concerns in earlier years. Those above 50 constitute 38.3%, signifying distinct challenges in older age. With 61.7% males, Gram stain analysis reveals microbial diversity. Notably, Ciprofloxacin (90%) and Cefipime (98.3%) exhibit high resistance, while Cephradine (48.3%) and Cefoxitin (20%) show sensitivity. Meropenem and Vancomycin display moderate resistance (28.3% and 25%), while Tigecycline (10%) and Teicoplanin (1.7%) exhibit lower resistance, offering insights for effective treatment strategies. Conclusion: Our study reveals notable antibiotic resistance, with Ciprofloxacin (90%) and Cefipime (98.3%) exhibiting high resistance. Conversely, Cephradine (48.3%) and Cefoxitin (20%) show sensitivity, guiding tailored treatment strategies for deep skin and soft tissue infections.

Angiosarcoma of External Auditory Canal Masquerading as Pyogenic Granuloma

Sarcomas are rare and heterogeneous mesenchymal tumours that occur in deep soft tissue and bone

Musculoskeletal glomus tumor: a review of 218 lesions in 176 patients.

To review the spectrum of clinical and imaging features of glomus tumor involving the musculoskeletal system including the typically solitary forms as well as the rarer multifocal forms (glomuvenous malformation and glomangiomatosis). A retrospective review of our institutional pathology database from 1996 to 2023 identified 176 patients with 218 confirmed glomus tumors. Primary imaging studies included MRI (125), radiographs (100), clinical/intraoperative photos (77), and ultrasound (36). Lesions were divided into two groups: those that are typically solitary involving specific anatomic areas (finger, toe, soft tissue, coccyx, and bone), and those that are multifocal (glomuvenous malformation and glomangiomatosis). The finger was the most frequently involved anatomic location for the classic (sporadic) glomus tumor occurring in 51% of patients, 77% of which were women, with the nail plate involved in more of the 75% of cases. Sporadic lesions involving the skin, subcutaneous adipose tissue, and deep soft tissue were termed "soft tissue," and were identified in 39% of patients, 90% of which were in the extremities and in men in 81% of cases. The multifocal syndromic forms of glomus disease occurred in younger individuals and involved less than 6% of the study group. Patients with glomuvenous malformation presented early with predominantly cutaneous involvement, while those with glomangiomatosis present later, often with both superficial and deep involvement, and a high rate of local tumor recurrence. While glomus tumor is generally uncommon, it frequently involves the musculoskeletal extremities. Knowledge of the spectrum of characteristic locations and appearances will facilitate definitive diagnosis.