Foul-smelling Fluid Research Articles

Primary Breast Necrotising Fasciitis in an Elderly Woman Managed with Nipple–Areola Conservation and Delayed Primary Closure in a Resource-Poor Setting A Case Report

Abstract Primary breast necrotising fasciitis is a rare disease that can rapidly progress with high morbidity and mortality rates. Due to its rare occurrence, it is often misdiagnosed. This case was a 65-year-old, obese, immobile, and newly diagnosed woman who presented with a 2-week history of progressive left breast pain and swelling with associated darkening of the breast skin and discharge of foul-smelling fluid. There was no history of fever and the nipple–areola complex was spared. The surrounding healthy skin has a characteristic peau d’orange and erythematous. Two discrete and slightly tender left axillary lymph nodes were noted. At the presentation, her blood sugar was high. Initially, a breast malignancy was suspected but later an ultrasound showed increased fibrous and fatty tissue architecture of the mammary gland. It also noted inflammatory collections within the mammary glands and thus concluded breast inflammation. Early intervention with antibiotic cover and wound debridement forestalled the progress of the disease and nipple–areola salvage. The wound was later covered by delayed primary closure after 14 days of wound dressing with a silver-based solution. Breast asymmetry was noted as a surgical complication. Early aggressive intervention in necrotising fasciitis of the breast in an elderly woman with comorbidities contributed to the preservation of nipple–areola complex with eventual satisfactory management using direct wound closure.

Fournier's Gangrene in 21 Years Old Female: A Case Report

Introduction: Fournier's gangrene, also known as gangrene of the genital region, is an uncommon and rapidly advancing form of necrotizing fasciitis that affects the genitals. The severity and mortality of the disease are dependent upon the overall health status of the patient at the time of diagnosis and the speed at which the infection spreads.
 Case presentation: An unmarried 21-year-old woman presented with a persistent discharge of abscesses in the perineal area. The patient came in ambulatory and showed no indicators of heart or lung discomfort. A pelvic examination was performed, and the following observations were made: A visual examination revealed swelling in the vulvar area on both sides, along with an open wound within the swelling measuring 3×3 cm. The wound was discharging reddish, thick, and foul-smelling fluid. A glucose level of +4 was observed in the urine, and a random blood sugar test yielded a value of 324 mg/dl. The patient received wound debridement, excision, and electrocauterization of genital warts, blood sugar monitoring with insulin administration, and a 14-day course of antibiotics. The patient's condition improved, and they were discharged after receiving 14 days of intravenous antibiotic treatment.
 Conclusion: The treatment of Fournier gangrene requires a comprehensive approach that includes intensive systematic management, broad-spectrum antibiotic therapy, and early surgical debridement. This involves removing the necrotic tissues and surgically draining the peritoneum, scrotum, penis, and inguinal regions.

P-062 SEVERE COMPLICATION AFTER EVENTROPLASTY: NECROSIS OF RECTUS ABDOMINIS MUSCLES

Abstract Aim Rectus abdominis muscles are supplied mainly by superior and inferior epigastric arteries, forming an arcade between them. The ligation of one of them during a surgical intervention usually has no clinical repercussions. However, when both arteries flow are interrupted, there is another clinical scenario. Material and Methods We describe the case of a 74 years-old woman who was admitted for an elective surgery of fourth recurrence of a midline eventration (M2-5W3 European Hernia Society Classification). We treated using preoperative botulinum toxin and Rives-Stoppa surgical technique. On the second postoperative day, the patient suffered a cardiorespiratory arrest due to a pulmonary embolism, therefore anticoagulation was necessary. After anticoagulation the patient showed severe anemia (Hemoglobin 5 g/dL) and tomography computed scan images revealed a big hematoma of the abdominal wall with active bleeding. Results Embolization of both epigastric, right mammary and left pectoral arteries was performed by interventional radiologists. After 12 days, the patient showed cutaneous surgical wound dehiscence and serohematic foul-smelling fluid. We detected necrosis of the rectus muscles when we debrided the wound. It was treated with daily cures and vacuum therapy without mesh removal, achieving a progressive closure. After six months of follow-up, there are no signs of recurrence. Conclusions Ischemia of the rectus muscles is a severe complication after eventroplasty that can be treated with debridament of necrotic muscle and vacuum therapy, without removal of mesh if it is sufficiently extended along the healthy abdominal wall and cover the necrotic defect.

A RARE CASE OF ACTINOMYCES EMPYEMA

A RARE CASE OF ACTINOMYCES EMPYEMA

Clostridial enterocolitis in an emu (Dromaius novaehollandiae)

Clinical History: A 25-year-old female emu (Dromaius novaehollandiae) presented with a 1-week history of lethargy, hyporexia, and recumbency. The bird had lived its entire life at the Winnie Carter Wildlife Center in Texas and had an unremarkable medical history, apart from bilateral congenital blindness. Necropsy Findings: Within the coelomic cavity, the serosal surface of the intestines was coated with a moderate amount of tan to green, mucoid, opaque, foul-smelling fluid (fibrinoheterophilic coelomitis) (Fig. 1). The large intestine was diffusely dilated and filled with dark red fluid and strands of yellow, friable material (fibrin). The mucosa of the small intestine, and most severely the colon, was diffusely roughened, thickened, dull, and covered by a thick yellow to green, opaque, friable diphtheritic membrane (Fig. 2). The distal colon was diffusely, markedly distended and focally contained a 50x7x5 cm, semi-firm accumulation of feces coated by a 4-5 mm diameter layer of tan, friable material (fibrin) located 21 cm from the opening of the cloaca. Gross evaluation of the eyes revealed bilateral aphakia.

Anterior urethral erosion: report of a malfunctioned and infected artificial urinary sphincter

Background: Since its introduction in less than a century, artificial urinary sphincter (AUS) remains the gold standard in the treatment of severe male sphincter weakness incontinence. It is an extremely reliable prosthesis and patient's satisfaction rate is high after successful implantation. However, complications can occur following implantation and one of the most feared complications is anterior urethral erosion from sphincter malfunction and failure. As patients embark on medical tourism, Urologists in our environment may be challenged with complications resulting from various interventions not readily available in our environment.Case Summary: A 15 year old male student presented to our facility with fever of one week duration and painful scrotal swelling which ruptured spontaneously discharging purulent foulsmelling fluid two (2) months following successful implantation of AUS at a hospital in India. He was febrile with temperature of 38.70C, respiratory rate 32 cycles/minute, pulse rate 110 beat per minutes and blood pressure of 100/60mmHg. His packed cell volume was 34 % other laboratory parameters were not remarkable. He was managed for urosepsis with intravenous infusion, parenteral antibiotics, and initial wound debridement and subsequent AUS ex-plantation and perineal urethrostomy. Patient did well and he is awaiting urethroplasty and AUS placement.Conclusion: Artificial urinary sphincter removal and perineal urethrostomy is a viable option for the emergency management of anterior urethral erosion due to malfunctioned infected artificial sphincter.Keywords: Anterior urethral erosion, artificial urinary sphincter, Urosepsis, perineal urethrostomy, urethroplastySavannah Journal of Medical Research and Practice 2018;7(1):23-27

Acute Appendicitis and Small Bowel Obstruction Secondary to Metastatic Breast Cancer

Introduction: Breast cancer is the most common cancer in women, it is well known to metastasize to lymph nodes, lungs, liver, brain, and bones. However, luminal gastrointestinal metastasis is rare, especially to the appendix. Herein, we report a case where the cancer metastasized to the ileum and appendix causing acute appendicitis and small bowel obstruction. Case summary: A 44-year-old female with a history of stage IV metastatic breast cancer to bones, lungs and ovaries, presented with acute abdominal pain for one day. She was diagnosed 3 years prior to presentation with right invasive lobular carcinoma (estrogen and progesterone positive, HER-2 negative), she had right mastectomy and was started on tamoxifen. One year later she had metastasis to the left breast and lungs, so she was started on Exemestane and Everolimus with stability in disease till her current presentation. On the current presentation her pain was generalized and associated with nausea, vomiting and constipation. Her abdomen was soft, distended with generalized tenderness. A Computed tomography of the abdomen and pelvis showed partial small bowel obstruction and swollen appendix but did not meet the diagnostic criteria of acute appendicitis (Figure 1-2). Her symptoms worsened despite conservative treatment, so she was taken to the operating room for exploratory laparotomy where she was found to have a markedly dilated ileum with peritoneal implants, in addition to an inflamed and edematous appendix surrounded by a foul-smelling fluid collection, so she underwent ileocecectomy, appendectomy, and lysis of adhesions. Pathology showed metastatic breast cancer in the mesentery, appendix and small intestines with findings consistent of acute appendicitis. Her post-operative course was uncomplicated, and she was discharged home with follow up with surgery and oncology.Conclusion: Small intestinal and appendiceal metastases of breast cancer are very rare, though it should be considered in the differential diagnosis in cancer patients presenting with acute abdominal pain.2486_A Figure 1. A CT scan of the abdomen (cross section) showing a fluid-filled loop of the small bowel suspicious for transitional segment of obstruction.2486_B Figure 2. A CT scan of the abdomen and pelvis (coronal section) where part “A” is showing a dilated bowel lobes suggesting intestinal obstruction, and part “B: is showing a swollen appendix.

Natural history, presentation, and diagnosis of hidradenitis suppurativa.

The diagnosis of hidradenitis suppurativa (HS) is based on a characteristic history and physical exam. The anatomic sites of involvement include the axillae (most common), groin, and buttocks, and the perianal, perineal, and mammary regions. Initially, HS manifests with open comedones (usually with two or more "heads") and tender subcutaneous acneiform papules. Without intervention, the natural history of HS is chronic and progressive. More painful subcutaneous nodules form, which rupture and drain a thick, mucopurulent, foul-smelling fluid. Later, sinus tracts form, and, over time, ropelike fibrotic subcutaneous scarring occurs, which can lead to disabling contractures of the affected limbs. Clinically, the severity of disease is classified using the Hurley staging system, which provides guidance for choosing among treatment options.

The Evaluation of Small Intestinal Volvulus Caused by Pathogenic microorganisms in a Thoroughbred Mare

Background: Small intestinal (SI) volvulus is defined as a rotation of greater than 180 degrees about its mesentery of a segment of jejunum or ileum. Horses of all ages have been affected. There is typically an acute onset of signs of mild to severe pain. Objectives: The objective of this study was to evaluate the microbial pathogens of the duodenum, ileum, cecum, colon and rectum (feces) in associated with volvulus horse, and to determine whether rectal (fecal) samples are representative of proximal segments of the gastrointestinal tract. Materials and Methods: A brown 26 years old mare, BCS (body condition score) 4 was found dead in stall in the morning. It was moved to a suitable area to conduct a post-mortem exam. The mare was examined in hanging position and then left lateral-recumbent. Advanced abdominal tympany was present. Clinical signs, laboratory data, surgical or necropsy findings, clinic-histopathological findings and outcome for horse with SI volvulus was obtained from medical records, and identified by manual review. Horsefeces and colon were collected in autopsy. Fecal material was scooped from the center of a freshly defecated bolus into sterile sample cups, which were placed into plastic anaerobe jars with PackAnaero sachets (Mitsubishi Gas Co. via Remel, Lenexa, KS) and transported to the laboratory. Alternatively, colon contents were collected from horse at the autopsy by direct incision into the colon immediately after the horse was autopsied. The samples were transported anaerobically to the laboratory. Results: On opening the abdominal cavity; a large quantity of sanguineous, foul-smelling fluid with pus exited the perforated bowel wall (hemoperitoneum). Additionally, signs of an acute diffuse peritonitis were visible. The blood vessels of the stomach and intestines were distended. Small intestinal volvulus was observed in several segments (360 degree rotation involving the mesentery). This information may aid diagnosis and prognosis and guide to decision making for horses with this condition. ??????

Necrotizing Panniculitis, a Skin Condition Associated with Acinar Cell Carcinoma of the Pancreas

Purpose: Pancreatic panniculitis is a rare cutaneous eruption due to leak of pancreatic lipase into the bloodstream with subsequent focal necrosis of adipose that is sometimes associated with panceatic disease. We describe an unusual patient with this skin condition who presented to our hospital for evaluation of skin lesions of uncertain etiology with associated diarrhea and arthralgias. Methods: A sixty-one year old man complained of a four month history of subjective fever, pain in his ankles, knees and wrists, and a painful rash that spread from his legs to the abdomen and arms. The cutaneous eruption comprised inflamed-looking papules and pustules on an erythematous base that drained dark, purulent, foul-smelling fluid. The patient also made note of diarrhea which had been progressive over four months. Lipase levels, drawn to investigate the patient's chronic diarrhea, were elevated to three hundred times the reference limit. Amylase, ALT, AST and bilirubin were mildly elevated. A CT scan of the abdomen revealed a mass in the tail of the pancreas with nodules in both the liver and the base of the left lung. A CT-guided needle biopsy of one of the liver nodules revealed histology consistent with Acinar Cell Carcinoma of the Pancreas. The cancer was stage IV at the time of presentation. The skin eruption was diagnosed to be nodular subcutaneous fat necrosis, also known as pancreatic panniculitis. The patient was offered palliative treatment. Results: Pancreatic panniculitis is rare, occurring in 2–3% of all patients with pancreatic disorders. Occasionally, it is associated with cancers of the pancreas, especially with acinar cell carcinoma which itself represents only one to two percent of pancreatic malignancies. As of 1995 fewer than 40 described cases of acinar cell carcinoma of the pancreas have presented with poly-arthralgia and disseminated fat necrosis, both seen in our patient prior to the discovery of his pancreatic malignancy. Conclusions: In clinical practice the skin manifestations of internal malignancies vary in their presentation. They may challenge primary care physicians and dermatologists when patients present without associated findings for malignancy. Panniculitis should be kept in mind in the differential diagnosis of inflamed appearing nodules and pustules with an erythematous base, such as the ones observed in our patient, particularly when they are progressive and unrelenting. They may be the clue to the discovery of a potentially serious disease.

Inguinal Lymphadenitis Caused by Entamoeba histolytica: Case Report and Literature Review

Inguinal Lymphadenitis Caused by Entamoeba histolytica: Case Report and Literature Review

Bitten by the Insect Bug

I must admit that I do not like insects. I try to avoid them as much as possible, not only by swatting away at any fly I see, but also by pushing aside unread most writing on insects. There seem to be two reasons for my aversion. One is early memories of my mother on cricket patrol on summer evenings. Insects were something to be crushed if they dared venture inside the house. Spiders, worms and everything else classified as creepy crawlies received the same treatment-rapid extermination. It never dawned on me that some people thought of caterpillars as beautiful or spent hours observing the behavior of beetles. Nor did my estimation of invertebrates in general improve when I became a biology major. Invertebrates were disgusting rather than interesting organisms since they were usually presented as pickled specimens floating, and often decomposing, in foul-smelling fluid. To make them even more distasteful, they were used merely as problems in classification. What organisms had radical versus bilateral symmetry? What differentiated arachnids from arthropods, or roundworms from flatworms? But even as inveterate an invertebrate hater as myself cannot avoid sixlegged creatures completely. Insects are everywhere, abundant both in quantity and variety. As John Alcock has written: When you consider that there are several million species of insects, each wonderfully distinctive, and fewer than 10,000 species of birds, it is strange that there are millions of bird watchers but only thousands of insect enthusiasts. It occurred to me recently that among this relatively small band of enthusiasts are a large number of good writers, too good for even me to resist. Bernd Heinrich's In a Patch of Fireweed (1984), Karl von Frisch's Bees (1950), and Edward 0. Wilson's The Insect Societies (1971) immediately come to mind. But above them all stand two books which I found tremendously fascinating, and which changed my perception of insects. They are a collection of the writings of J. Henri Fabre, edited by Edwin Way Teale (1949), and Howard Ensign Evans's Life on a Little-known Planet (1984). These books have not made me love insects-just yesterday I crushed a beetle that crawled up my arm, rather than trying to classify it or observe its behavior. But these books have given me an appreciation for such creatures, at least on an intellectual level. From now on, when I discuss insects in class it will be less out of a sense of duty and more with a sense of wonder. The writings of Fabre and Evans are very different from each other. Though they both dedicated their lives