Foul-smelling Pus Research Articles

Unlocking Healing Potential: A Case Study on the Management of Diabetic Foot Ulcer

Diabetes stands as one of the most prevalent diseases globally, and diabetic patients are at risk of developing foot ulcers as a microvascular complication. These ulcers stem from diabetic neuropathy or atherosclerosis, leading to ischemia or breakdown of glucose-laden tissue, resulting in inflammation and ulceration. If left untreated, these ulcers can become infected, spreading to the underlying tissues. In Ayurveda, such ulcers are termed as Madhumehajanya Vrana. Sushruta Acharya outlined Anushastra Karma for managing Vrana, which includes Ksharakarma (application of alkalis) and Jalukavacharana (leech therapy). Kshara functions by actions like Chhedana, Bhedana, Lekhana and Ropana. Jalukavacharana possesses anti-inflammatory properties, promotes fresh blood supply by removing vitiated Dosha from the blood, and fosters wound healing by forming healthy granulation tissue. A 65-year-old female patient presented with a non-healing wound on the plantar aspect of her left foot below the greater toe since 8 months, associated with foul-smelling pus discharge for 6 months. She had a known history of diabetes mellitus since 10 years. The ulcer measured 4cm x 3cm x 2.5cm, GRBS was 380mg/dl with HbA1c of 12%. Patient was treated with Ksharataila infiltration, application of Tilwaka pratisaraneeya kshara followed by Lekhana of callosity present over the edges of the ulcer, and Jalukavacharana therapy for four sessions with seven days interval, in addition to internal medications. Glycemic control was achieved by Inj. Insulin Mixtard 30/70 30 units in morning and 15units at night.

Chronic Osteomyelitis of the Tibia in Children: About 01 Cases

Introduction: Chronic osteomyelitis is a chronic infection of the bone and marrow. It evolves in a tenacious and recurrent manner. Observation: 15 year old boy, not in school, without known ATCD, admitted for painful swelling of the left leg in whom the onset of the disease dates back to 04 years marked by pain in the left leg associated with a fever. On the locomotor examination we noted a painful swelling of the left leg with 03 fistulous orifices on the anteromedial aspect of the left leg; leaking foul-smelling pus. He benefited from a pus sample for a cytobacteriological study, a sequestrectomy, curettage and abundant washing with hydrogen peroxide and physiological serum. The postoperative course was simple. The patient was seen again at 10 months and he presented a good clinical, biological and radiological evolution. Conclusion: Chronic osteomyelitis mainly affects the young population. Pandiaphysitis with sequestra remains its clinical forms which pose enormous therapeutic problems.

Managing Maternal Sepsis after Delivering an Advanced Abdominal Pregnancy in Low Resource Setting Health Facility

Background: Abdominal pregnancy is a rare form of ectopic pregnancy with a higher misdiagnosis rate. Sepsis is a life-threatening complication associated with this type of ectopic pregnancy. Various techniques for managing septic advanced abdominal pregnancy have been discussed in the literature. In this article, we report a case of managing septic abdominal pregnancy in which a macerated baby was delivered, and the necrotic placenta was left in situ. Case presentation: We report a 34-year-old African woman, para 5 living 4, who was three days post laparotomy due to abdominal pregnancy. A re-laparotomy was done due to maternal sepsis. The peritoneum had foul-smelling pus, with a necrotized placenta which was still attached to various parts of the abdomen. The placenta was left in situ and the abdomen was left open. Pus swab revealed methicillin-resistant staphylococcus aureus which was sensitive to Vancomycin. She was managed with a ten-day Vancomycin regime. Dressing with normal saline and honey twice or thrice a day for eight weeks was done. Secondary suturing was done and the patient was discharged home later in good health. Conclusion: Advanced abdominal pregnancy is a rare condition, and its management is very challenging. Once it complicates into maternal sepsis the life of the mother becomes endangered. Identifying and treating the source of infection with daily dressing using normal saline and honey is simple and cheap, it saves life.

EP-157 Pyocystis: A silent complication of a supravesical urinary diversion

Abstract Aim Pyocystis is an important yet overlooked rare complication of a non-functioning urinary bladder. It is due to collection, liquefaction and decomposition of shed bladder epithelium, resulting in accumulation of pus in the bladder causing sepsis. We describe a case of Pyocystis in a patient with bilateral nephrostomies who presented with urosepsis multiple times due to this complication. Case Report A 78-year-old man, known case of Ca Prostate wit bilateral nephrostomies warranted multiple subsequent hospital admissions in one month due to urosepsis presenting with fever, urethral discharge, suprapubic pain and very high inflammatory markers. He underwent a CT Abdomen & Pelvis which revealed markedly distended bladder despite nephrostomies in place. Upon catheterization, no urine output was observed which raised concerns. An attempt at bladder washout displayed a large amount of thick foul-smelling pus which was aspirated. This was sent for culture and patient was commenced on appropriate IV antibiotics. After a thorough bladder wash out under flexible cystoscopy, patient was eventually discharged on a long-term catheter with regular bladder washouts in community as required. Patient was successfully managed on conservative treatment. Conclusion Pyocystis can sometimes be a missed complication of urinary diversion or a non-functioning bladder that can present silently under sepsis and should therefore be considered as a differential diagnosis of sepsis in patient with supravesical urinary diversion. We wanted to highlight this condition which if left undiagnosed will progress to severe sepsis and possible death. Hence prompt intervention and aggressive management is vital. Treatment for this complication requires catheterization, bladder irrigation and antibiotics.

Penile strangulation, a study of two cases.

IntroductionPenile strangulation is one of the rarest clinical findings. So, we aimed to present the clinical case of two cases that we encountered at our institute.Presentation of casesCase 1. A 26-year-male with bipolar disorder presented to emergency room with complaints of metallic ring entrapment in the penis for 4 days. A gold-plated metallic ring measuring 1 × 0.25 cm was found encircling the coronal sulcus along with foul-smelling pus and slough underneath as a result of necrosis of the skin. Jumbo cutter was used to cut the ring. Loose sutures were applied to the injured part with debridement. Case 2. A 66-year-old man presented to emergency with complaints of penile swelling and poor urinary stream for the last 2 days. Local examination showed a plastic ring of water bottle seen stuck at the root of penis. Distal penis was edematous with multiple areas of skin discoloration and petechia. The ring was cut with simple surgical scissor.DiscussionThis clinically emergency condition may lead to wide range of vascular and mechanical injuries if the treatment is delayed. Plastic rings can be easily cut out whilst metallic objects which are thick and hard are difficult to remove. Pliers' application or use of jumbo cutter as in one of our cases is beneficial for prompt release of edematous pressure and salvage of the penis.ConclusionPenile strangulation due to foreign body is a rare clinically emergency condition. Urgent intervention is necessary to remove the object causing constriction along the penis.

Management of Ludwig's Angina at a Tertiary Care Hospital in Western Region of India

IntroductionLudwig’s angina is cellulitis of submandibular space, submental space, and sublingual space. The main causative factors include dental infections (dental caries with atypical periodontitis, pericoronitis, and dental procedures). Other predisposing conditions include poor dental hygiene, dental caries, malnutrition, diabetes mellitus, AIDS, and various other immunocompromised states. It presents as an acute onset and spreads very rapidly causing bilateral diffuse neck swelling, edema of floor of mouth, pain, fever, trismus, foul-smelling pus discharge, difficulty in swallowing, airway edema, and tongue displacement creating a compromised airway with stridor. So it requires early diagnosis and aggressive management.Material and methodsClinical data of all patients with clinical diagnosis of Ludwig’s angina managed at the Department of Otorhinolaryngology-Head and Neck Surgery, Sir Takhatsinhji (T) General Hospital and Government Medical College, Bhavnagar, India, from 2015 to 2019 were analyzed retrospectively in this study.ResultOver the review period, 30 cases were diagnosed as Ludwig’s angina, out of which 12 (40%) were males and 18 (60%) were females; male to female ratio was 1:1.5. The age of the patients ranged from six months to 64 years, with a mean age of 38.86 years. Fever, neck swelling, and neck pain were present in all patients.In 16 patients, incision and drainage were done under general anesthesia while the rest five patients required only local anesthesia. In six patients (20%), for maintenance of airway, tracheostomy was required. The most common complication was necrotizing fasciitis and death followed by septicemia. Mortality was observed in three patients (10%) in this study.ConclusionDespite improved outcomes compare to pre-antibiotic era, Ludwig's angina still remains a potentially life-threatening disease in ENT at present. Dental caries, uncontrolled diabetes mellitus, and malnutrition are commonly associated conditions. With early diagnosis, close airway observation, aggressive intravenous antibiotic treatment, and timely surgical intervention, morbidity, and mortality can be reduced.

Recurrent obstructive uropathy secondary to pyometrocolpos in an 8-month-old infant: a case report

BackgroundPyometrocolpos is accumulation of infected fluid in the uterus and vagina. It is rare in children, mostly seen after menarche as a result of obstructive congenital genital malformation that impairs free drainage of the uterine secretions. In a child, it may present as an acute illness that necessitates urgent and appropriate management and treatment of the underlying cause, which can be a challenge in a resource-limited setting.Case presentationWe report a case of pyometrocolpos in an 8-month-old African infant who presented with fever, vomiting, decreased urine output, and abdominal distension of 12 days’ duration. An abdominal examination revealed a subumbilical midline incision scar and a midline lower abdominal mass. She appeared to have presented at the emergency department with similar complaints 2 months earlier and had been diagnosed with pyometra, which was managed by emergency laparotomy for pus drainage, and she was kept on antibiotics. Recovery was established after 10 days of admission, and the patient was discharged to home. Her symptoms reappeared 2 months after the first presentation. Her blood work showed significant leukocytosis with neutrophilia, and abdominal ultrasound depicted bilateral hydronephrosis with hydroureters and a fluid-filled uterus. Examination under anesthesia in the operating theater revealed normal-looking female genitalia with a cribriform hymen, beneath which lied a transverse vaginal septum. Foul-smelling pus was aspirated through the septum, and septectomy was performed to allow 350 ml of pus to drain. A pus sample was sent for culture and sensitivity, and Escherichia coli sensitive to ceftriaxone and gentamicin was isolated.ConclusionPyometrocolpos is rare in childhood but should be suspected in a girl presenting with a midline lower abdominal mass accompanied with urinary obstructive symptoms associated with fever and gastrointestinal symptoms. Escherichia coli seems to be the most probable offending organism, but pus culture is crucial for antibiotic stewardship in proper management of the infection. Definitive treatment should focus on correcting the obstructive anatomical congenital deformity that caused the obstruction in order to avoid recurrence.

Paraneoplastic anti-NMDA receptor encephalitis in 1830?

ObjectiveOur aim was to identify patients with probable anti-NMDA receptor encephalitis among historical medical cases.MethodA case report published in leading Hungarian-, German- and Italian-language medical journals in the early 1840s was revisited.ResultsIn 1830, an 18-year-old, healthy woman suffered epileptic seizures, followed by a 6-day-long state characterized by catalepsy, unresponsiveness, motionless, and light breathing. Her symptoms regularly returned in the following 1.5 years. Meanwhile, a progressively growing huge abdominal tumor appeared. One day, she suddenly started vomiting a large amount of foul-smelling pus mixed with blood, accompanied by bone fragments. Pus mixed blood with some membranous substance was also evacuated through the anus and vagina. After this event, she completely recovered; 1.5 years later, she married and later gave birth to 3 healthy children. The patient remained healthy during the 11-year follow-up.ConclusionsWe suggest that in the description of a paraneoplastic case, an anti-NMDA receptor encephalitis can be dated back as far as to the 19th century, with an especially rare type of resolution: the disappearance of the symptoms after the spontaneous elimination of an ovarian teratoma.

Management of Sacrococcygeal Pilonidal Sinus by Ksharasutra

Pilonidal sinus is a worldwide problem found commonly in young hirsute men. The incidence is observed to be 26/100,000 person with 3:1 male predominance. This disease clinically simulates Nadivrana (K14) described in Ayurveda. Many surgical techniques have been described and performed as a treatment for chronic pilonidal sinus. But up to 40% of patients develop recurrence and surgery may cause loss of the intergluteal tissue and other side effects. A 29-year-old nonsmoker, nonalcoholic male student with complaints of a dimple-like depression on the skin surface at upper part of intergluteal cleft associated with pain while sitting or standing, and intermittent discharge of foul-smelling pus and blood draining from the cleft visited the Outpatient Department of Central Ayurveda Research Institute for Cardiovascular Diseases, New Delhi for Ayurvedic management. On examination, there was swollen hyperemic skin around the area which is tender on palpation with hair protruding from the lesion and one visible sinus tract on the skin of cleft. It was diagnosed as pilonidal sinus. After doing the essential laboratory investigations, Ksharasutra therapy was endeavored to treat this disease under local anesthesia. The Ksharasutra was changed weekly after the initial sitting and an Ayurvedic formulation Triphala Guggulu in a dose of 1 g twice a day for 28 days was given orally and local dressing with Jatyadi Tail was performed daily for 28 days. After 28th day of therapy, the tract was completely cut out and healing was observed. There was complete resolution of symptoms like pain and discharge and the sinus tract also got healed. No side effects or adverse drug reaction was found during the therapy. After complete healing of the tract, the patient was followed up for a period of 180 days, with visits in every 30 days and no occurrence was observed. Hence, this therapy can be practiced safely for the treatment of sacrococcygeal pilonidal sinus.

PS01.084: BOERHAAVE SYNDROME: CONTINUING CHALLENGE TO TREATMENT

Abstract Background Boerhaave syndrome produces an extremely severe clinical profile due to extravasation of digestive secretions and food into the mediastinum and pleural space. Diagnosis is often delayed, since it is a rare disease and is usually confused with other equally serious pathologies. These factors contribute to its high mortality rate. We present a case which was previously treated in three different institutions and finally referred to our department. Methods 81 year old gentleman was diagnosed as Boerhaave syndrome on 23rd Jan 2017. He had treatment in three different institutions: right ICD in first center: feeding jejunostomy and venting gastrostomy in second center: over the scope clipping and hemoclip in third center. As he continued to have persistent leak of enteral contents and purulent discharge in ICD, he was referred to our department for further management, two months after the intial insult. Results Patient was optimised for surgery and transhiatal esophagectomy with esophago gastric anastomosis was done in our department. Operative findings: Abdomen entered through midline incision, hiatal peritoneum incised, gastro esophageal junction encircled and esophagus mobilised. It revealed purulent discharge from right hemithorax and a 4cm esophageal perforation along right lateral aspect of esophagus above GE junction.About 120ml of foul smelling pus drained. Considering unhealthy esophageal tissue, long rent and failed endotherapy it was decided to do transhiatal esophagectomy. Previous gastrostomy site closed in 2 layers with 3–0 PDS. Through left anterior sternomastoid incision cervical esophagus mobilised and transected at low neck level and the specimen was removed through the hiatus. A gastric tube was made with linear staples and brought into neck through posterior mediastenum by camera sheath technique. Esophago-gastric anastamosis completed with posterior stapled and anterior hand sewn technique. Post op period was uneventful. Conclusion Early diagnosis and appropriate therapeutic strategies can reduce the mortality rate of Boerhaave's syndrome. Early intervention reduces the morbidity and mortality. The mortality increases with increasing time post insult. our patient who had undergone multiple theraputic modalities in three different centers was succesfully managed with trans hiatal esophagectomy in our department. Disclosure All authors have declared no conflicts of interest.

Misfitting Together

Misfitting Together Jon Davies (bio) Before Pictures by Douglas Crimp. Brooklyn, NY: Dancing Foxes Press, and Chicago: University of Chicago Press, 2016. Pp. 288, 151 illustrations. $39.00 cloth. This lavishly illustrated book charts art historian and critic Douglas Crimp's first decade in New York from his arrival in 1967 up to his curating the much-mythologized exhibition Pictures at Artists Space in 1977. While Crimp is perhaps best known for this project, his 1987 AIDS: Cultural Analysis/Cultural Activism special issue of October—where he worked as an editor for thirteen years (247)—and his 2002 Melancholia and Moralism: Essays on AIDS and Queer Politics are invaluable volumes in queer cultural studies. Crimp has been a mentor to and influence on a generation of queer practitioners and thinkers, providing a model for how to gracefully articulate politics, aesthetics, and affect in times of crisis, famously declaring of AIDS that ultimately, "It is our promiscuity that will save us."1 A striking anecdote from his 1989 essay "Mourning and Militancy" that reappears in Before Pictures reads, In 1977, while I was visiting my family in Idaho, my father died unexpectedly. He and I had had a strained and increasingly distant relationship, and I was unable to feel or express my grief over his death. After the funeral I returned to New York for the opening of an exhibition I'd organized [Pictures] and resumed my usual life. [End Page 141] But within a few weeks a symptom erupted which to this day leaves a scar near my nose: my left tear duct became badly infected, and the resulting abscess grew to a golf-ball sized swelling that closed my left eye and completely disfigured my face. When the abscess finally burst, the foul-smelling pus oozed down my cheek like poison tears. I have never since doubted the force of the unconscious. (247) Crimp's memoir of his first decade in New York—which, not incidentally, also saw the emergence of a thriving gay sexual subculture—similarly seeks to retroactively return the body and its drives to his youthful intellectual engagement with the discourse of contemporary art. Often Crimp's juxtapositions of gay life and art world, personal and professional, are stark, suggesting that they can only partially be bridged with the passing of time and with recourse to the queer vocabulary that Crimp himself has helped develop. (David Velasco's review of Before Pictures in Artforum aptly observes that Crimp's writing itself seems to dance between "memoir" and "theory" from "paragraph to paragraph."2) The book is loosely structured by the neighborhoods and the specific addresses that Crimp lived in as he moved south from Spanish Harlem to Chelsea to Greenwich Village to Tribeca and finally to the Financial District apartment in the beautiful Bennett Building that he has inhabited since 1976. The first chapter discusses his escape from his family in Coeur d'Alene, Idaho, in 1962, and his early art studies in New Orleans. His architecture education there, under the tutelage of a "spectacularly flitty" professor, toured him through ancient temples, Renaissance palazzi and local Gothic revival houses (9); these seemed to become spaces of imagination and possibility for him, glamorous alternative "homes" to the nuclear family he fled. This attention to the affective energies of private and public spaces inflects Crimp's narration of the built landscape of New York, whose changes greatly influenced the city's artistic production. Where Crimp lived played a determining role in which world he fell more into; his move from the Village to Tribeca, for example, came from a decision to "get serious about being an art critic" and "exchange … one scene for another" (148). When Crimp arrives in New York, he seems to effortlessly fall into an art world full of opportunity—a small scene marked by an openness and ease, which now seems as unimaginable as cheap, cavernous Manhattan lofts. Max's Kansas City, with the "tough-minded" male artists in the front room and the camp, [End Page 142] queer Warhol crowd in the back, is Crimp's spatial metaphor for his own split consciousness and youthful ambivalence about how gay and art worlds fit...

Purulent pericarditis caused by Klebsiella pneumoniae in a Nigerian Child

In the Western world, cases of purulent pericarditis have become almost nonexistent with progress and advent of new immunizations against many causative organisms. We report Klebsiella pneumoniae pericarditis, a rare cause of this uncommon disease, hitherto unreported in Nigeria. K. pneumoniae, which is a rod-shaped, Gram-negative, facultative anaerobe, produces extended-spectrum beta-lactamases; hence, it is usually resistant to a lot of antibiotics and is associated with a significant case fatality rate. Our 13-year-old male patient had septic arthritis of the right hip joint came with a 3 weeks complaint of difficulty with breathing. He had respiratory distress, tachypnea, and tachycardia. Although blood pressure was normal, he had pulsus paradoxus, elevated jugular venous pressure, diffuse apex beat, and heart sounds were distant. Chest radiograph revealed an increased cardiothoracic ratio (0.86) with “water bottle” appearance. Transthoracic echocardiography confirmed pericardial effusion with cardiac tamponade. Echo-guided pericardiocentesis was done, and 340 ml of foul-smelling and creamy pus with greenish tinge was aspirated and this grew K. pneumoniae sensitive to ciprofloxacin and gentamycin but resistant to other conventional antibiotics. Recovery was complete after a week of pericardial tube drainage and 3 weeks of treatment. To the best of our knowledge, this is the first case of Klebsiella - induced pyopericardium and with successful management in a Nigerian child. Pyopericardium may follow rare causes such as K. pneumoniae infection with its unique antibiogram.

Simultaneous bilateral femoral neck fracture following tetanus in a healthy adult

A 45-year-old trader presented to us with 4 weeks history of difficulty in opening his mouth, inability to walk and tonic–clonic seizures with bilateral femoral neck fractures. Three weeks before the onset of problems, the patient had been knocked down by a tricycle and had sustained an open wound over the right medial malleolus; the wound was sutured at a general hospital and the patient discharged home. One week later, the wound started discharging a foul-smelling pus and was dressed at a primary health centre; however, by the second week, the patient started having difficulty in opening his mouth. By the third week, he was bed ridden, developed tonic–clonic seizures and felt a crunching sound associated with severe pain in both hips. He was taken to a traditional bone setter who gave him some herbs, but his symptoms got worse. He was then brought to the Accident and Emergency Department of the University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria where a diagnosis of tetanus was made. Further evaluation revealed Gardener-type IV bilateral femoral neck fractures. He was managed for the tetanus, underwent bilateral bipolar hemiarthroplasty and was discharged home. He spent 10 weeks in the hospital.

Primary Ovarian Abscess Arising Spontaneously within an Endometrioma: A Rare Case

We report a very rare case of de novo abscess formation inside an endometrioma without any prior intervention in a 32-year-old woman. She presented with acute abdominal pain and persistent high-grade fever. A lump was palpable and tender and showed features of endometrioma on ultrasound. Laparotomy was conducted, as her clinical condition deteriorated despite broad spectrum antibiotics, and her fever did not subside. Thick foul-smelling pus was drained from the endometrioma, and the abscess wall was removed, followed by cystectomy. The patient improved markedly and did well in the postoperative period.

A case of pyometra treated with endoscopic ultrasound-guided drainage.

A 90-year-old woman was admitted to our hospital because of a high-grade fever and appetite loss. On computed tomography scan, a huge cystic lesion about 10cm in diameter was observed in the pelvic cavity, attached to the vagina and the neck of uterus. Pyometra was strongly suspected; however, a probe could not be inserted into the opening of the uterus because of atrophic changes. Therefore, we decided to perform endoscopic ultrasound (EUS)-guided drainage of the pyometra using the transrectal route. Foul-smelling yellow-brown pus was aspirated. A guide-wire was inserted and a 7Fr catheter was inserted into the pyometra through an external fistula. We thus completed the treatment of pyometra without surgical resection.

Cervicofacial Necrotising Fasciitis of Odontogenic Origin: A Review

A ‘Killer or flesh eating Bug’ as known to the Military surgeon of past centuries [1] was due to its nature of rapid spread along the facial planes to involve the sub cutaneous tissues, fascia, skin and possibly muscle[1,2]. Copious amount of foul-smelling pus are typically produced. Blood vessels become thrombosed, and ultimately tissue death occurs [1,3]. Now well known as Necrotizing fasciitis, due to presence of innumerable data, has become a common complication as an exacerbation of pre-existing infection.

Perinephric abscess caused by ruptured retrocecal appendix: MDCT demonstration

Acute appendicitis may occasionally become extraordinarily complicated and life threatening yet difficult to diagnose. One such presentation is described in a 60-year-old man who was brought to the hospital due to right lumbar pain and fever for the last 15 days. Ultrasonography showed a right perinephric gas and fluid collection. Abdominal computed tomography with multidetector-row CT (MDCT) revealed gas-containing abscess in the right retroperitoneal region involving the perinephric space, extending from the lower pole of the right kidney up to the bare area of the liver. Inflamed retrocecal appendix was seen on thick multiplanar reformat images with its tip at the lower extent of the abscess. Laparotomy and retroperitoneal exploration were performed immediately and a large volume of foul smelling pus was drained. A ruptured retrocecal appendix was confirmed as the cause of the abscess.

Cerebral Abscess

To the Editor: With the extensive use of effective broad-spectrum antibiotics, cerebral abscess is rare in developed countries.1-3 However, such lesions still poses a difficult challenge in the developing countries where the patients may get inadequate treatment for the pyogenic infections. A 68-year-old gentleman was treated with antibiotics at a peripheral center for multiple pus-discharging carbuncles in the right leg. He responded well to antibiotics, and his fever subsided. However, because of generalized weakness, he was lying in bed for a long time and developed multiple pressure ulcers on the buttocks. He was continually given antibiotics. Three days before admission to our hospital, he developed headache and lapsed into altered sensorium. At the time of admission, he was febrile (101°F). He had altered sensorium (Glasgow Come Scale, eye opening was nil, verbal response was groaning to pain, and motor response was flexion to pain), pupils were bilaterally equal and reacting to light. There was significant neck rigidity. Plain and contrast computed tomographic image showed well-defined ring enhancing lesion in the right occipital lobe with perilesional oedema and mass effect. Based on these findings, a diagnosis of cerebral abscess was made. The patient underwent emergency right parieto-occipital craniotomy. There was athin-walled cystic lesion containing yellowish foul-smelling pus. The lesion was excised completely. Pus culture grew Staphylococcus aureus, which was sensitive to vancomycin. There was no evidence of diabetes, and test result for HIV was negative. Initially, the patient was started on broad-spectrum antibiotics (ceftriaxone, amikacin, and metronidazole) that were changed to vancomycin administered via injection, after the culture report. The patient responded well to treatment. Brain abscess can result from direct or indirect cranial infections (trauma or infection of adjacent structures, eg, venous sinuses of the brain, paranasal sinuses, and teeth leading to brain infection by direct invasion) and metastatic septic abscess that spread from a systemic source to the brain.3,4 Although hematogenous spread of infectious emboli from a peripheral focus exclusively to the brain is very rare,5 in systemic spread, the infected thrombi can reach via systemic arterial circulation (eg, left-sided endocarditis) or via direct access to the systemic circulation (eg, pulmonary arteriovenous malformations).3,5 As in the present case, the occurrence of cerebral abscess with infectious sites lacking direct access to the systemic circulation (eg, right endocarditis, septic thrombophlebitis, and odontogenic or intra-abdominal abscess) is poorly understood.5,6 It is recommended that cerebral abscess should be considered in any ill patient who presents with pyrexia and neurological symptoms. Amit Agrawal, MCh Division of Neurosurgery Department of Surgery Datta Meghe Institute of Medical Sciences Sawangi (Meghe) Wardha, India [email protected] [email protected] Sudhakar Joharapurkar, MS Datta Meghe Department of Postgraduate Medical Education and Research Datta Meghe Institute of Medical Sciences Sawangi (Meghe) Wardha, India Anand Kakani, MCh Division of Neurosurgery Department of Surgery Datta Meghe Institute of Medical Sciences Sawangi (Meghe) Wardha, India Ankur Grover, MBBS Department of Surgery Datta Meghe Institute of Medical Sciences Sawangi (Meghe) Wardha, India

Verrucous carcinoma of the tibia arising after chronic osteomyelitis: a case report

Verrucous carcinoma is an uncommon complication of chronic osteomyelitis. The incidence of fistular carcinomas is reported to be between 0.21% and 3.36%. We present a case of verrucous carcinoma of the tibia arising after 58 years of chronic osteomyelitis. The primary presenting symptoms were acute pain, foul-smelling pus discharge and increasing lesion size. We used modern diagnostic investigations (biopsy, computed tomography, angiography, immunoscintigraphy, magnetic resonance tomography) to visualize the extent of the malignant lesion. No metastases were detected. Knee exarticulation was successful in treating the tumor and chronic infection in this case.

下縦隔にまで進展したｄｅｓｃｅｎｄｉｎｇ ｎｅｃｒｏｔｉｚｉｎｇ ｍｅｄｉａｓｔｉｎｉｔｉｓの１救命例

A healthy 55-year-old man was admitted to the department of oral surgery of our hospital for the treatment of severe odontogenic infection. Swelling of his neck with subcutaneous emphysema grew rapidly in spite of the use of antibiotics. On the fifth hospital day, Proteus mirabilis, and Prevotella buccae were cultured from the purulent, foul-smelling pus of his neck. On the seventh hospital day, as chest roentgenographic examination showed superior mediastinal widening with bilateral pleural effusions, he was transferred to our department for general management. A computed tomographic scan of the chest demonstrated an anterior mediastinal abscess with gas collection down to the level of the trunk of the pulmonary artery and a posterior mediastinal abscess along the descending aortic artery. Mediastinal drainage was done through a transcervical approach and the anterior region of his neck including the parapharyngeal space was left open. No organisms were found in the bilateral pleural effusions. We recommend thoracotomy when infection has spread below the carina anteriorly or the fourth thoracic vertebra posteriorly. In addition, we showed that transcervical drainage is a successful treatment of descending necrotizing mediastinitis (DNM) that extends to the inferior mediastinum without pyothorax.